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.

Posted on

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

 

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

 

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

 

Posted on

“When the patient fainted, her eyes rolled around the room”: How to make medical charting clear and accurate.

Recently Dr. Maurice Bernstein from The Keck School of Medicine, at University of Southern California, wrote into the listserve DR ED with this intriguing question:

I find many first and second year medical students present their patient write-ups for their instructor’s review with errors both typographical but also errors in presentation that makes statements seriously ambiguous.  I tell my students to read what they have written and then re-read again as an individual who knows nothing about the patient.  In addition, I have presented them with a list of “comic” but presumably also realistic medical charting errors. 

Is there something more I can do to teach the students to be more attentive particularly later when what they write for the record has greater clinical significance for the patient than a first or second year student?

MEDICAL CHARTING ERRORS 

  • By the time he was admitted, his rapid heart had stopped, and he was feeling better.
  • Patient has chest pain if she lies on her left side for over a year.
  • On the second day the knee was better and on the third day it had completely disappeared.
  • She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.
  • The patient has been depressed ever since she began seeing me in 1986.
  • Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.
  • The patient is tearful and crying constantly. She also appears to be depressed.
  • Discharge status: Alive but without permission.
  • The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.
  • Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.
  • The patient refused an autopsy.
  • The patient has no past history of suicides.
  • The patient expired on the floor uneventfully.
  • Patient has left his white blood cells at another hospital.
  • The patient’s past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.help pile of records
  • She slipped on the ice and apparently her legs went in separate directions in early January.
  • The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.
  • The patient had waffles for breakfast and anorexia for lunch.
  • Between you and me, we ought to be able to get this lady pregnant.
  • The patient was in his usual state of good health until his airplane ran out of gas and crashed.
  • She is numb from her toes down.
  • While in the ER, she was examined, X-rated and sent home.
  • The skin was moist and dry.
  • Occasional, constant, infrequent headaches.
  • Coming from New York, this man has no children.
  • Patient was alert and unresponsive.
  • When she fainted, her eyes rolled around the room.

After I finished giggling, I started to think…this is a problem with an educational and literacy component. What does educational pedagogy teach us to assist with this issue?

So here are a few ideas from my experience as an educator —these could be potential teaching strategies.   BTW, don’t do all of these…:)  1-3 should make some impact.

  1.  Work with this list: Give students the charting errors list above—it will be a good teaching moment for them and help them see how awful some of their errors could be.  You could ask them in partners (to share the fun) to correct the errors as best they can, reading between the lines, or to create a set of questions that would help clarify some of them. In other words, put them in the role of the teacher.
  1. Think of busy times: Ask students to list the times they may be most busy in a clinical setting.  This list should be posted for them to remind them that these are the times they need to slow down and focus most, ironically, on their writing.

    Busy? Slow down.
    Busy? Slow down.
  1.  Writing and recall for purpose:
think of the patient
Think of the patient.

a. Ask students to generate a list of purposes for charting; writing for purpose is a strong strategy for improving writing. I’m hopeful some of the purposes will be:  pay respect to the patient’s illness and the patient (patient-centred care), safe care for handover and for others reading the chart, legal documents for liability, etc.

b. Then, ask students to keep these in mind as they chart.  Mindful exercises could include using a symbol to associate with each purpose—drawing it, literally, or drawing it clearly in their minds, using a key word to help them recall, or if they tend to associate sounds, or colours with concepts, they could do that.

handover
Here’s my image for handover, for example. Don’t drop the baton.

Ask students pause for exactly 3 seconds prior to charting to collect their mind, to steady their writing and to recall these purposes.  Actually 3 seconds is like taking a deep breath.

NOTE:  thinking about the target audience, as in “Who potentially is going to read this?” can also achieve a impact.

  1.  Simulated chart exercise: Give students a simulated case and a chart exercise and a very stringent time limit.  Ask them to work in pairs and edit each other’s notes after the exercise.  OR, use “Pass It On” strategy, where students affix a nickname, or number to their work (to preserve anonymity and dignity :)) and pass the chart along to the left, so that at least 4 people get to weigh in on it with feedback.  NOTE:  this is also a good exercise in how to give feedback—warn them against being sarcastic, or harsh—their time will come! Ask students to practice good feedback techniques:  being specific, offering suggestions, avoiding judgements of the person, focusing on the writing, etc.
  1. Read the chart entry aloud.  Ask students to practice this.  This takes approximately 6 seconds at most (depending on the chart).  Reading a piece of writing aloud is another recommended editing strategy practiced by writers.

    each-word
    Read it out loud.
  1. Be careful with the use of abbreviations and acronyms which are not commonly used or can be ambiguous in interpretation. For their patient write ups, except for absolutely classic clinical acronyms such as C for “centigrade” or BP for “blood pressure”, the words should be written out such as “myocardial infarction” and NOT “MI” since MI could also represent “mitral insufficiency”. You could teach students that if any obscure acronym is to be used later on in the text, in its first use, the full expression should be written then followed in parentheses with the acronym noted.  Unfortunately, also, many acronyms or abbreviations in medical use are not written in a standardized manner between one institution and another and this can also lead to errors if not recognized. Bottom line: avoid or be really careful. (Thanks to Dr. Maurice Bernstein for this tip.)
  1. Avoid General statements: I got this feedback to a student from a nursing blog article by Katie Morales called 17 Tips to Improve Your Nursing Documentation.

Teacher: For example, you wrote “Dr. Smith called.” Did you mean: you called and are waiting for a return phone call; physician called nurse; or nurse called and spoke to physician?”  A better option is “MD

EmergencyResidencyStudents
Work with a partner and correct.

paged, assessment findings discussed, and no additional orders at this time.” 

 

Similar to strategy 1, I would give the students general statements where they can figure out what’s going on, similar to Ms. Morales’ example.  I’d work through one or two on the screen with the students first.

 

  1.  Checklist of common charting errors:  Making a checklist of these for students is helpful and having it handy when they are charting is also helpful (make it pocket-sized).  Checklists are a helpful literacy tool—no reason they shouldn’t work with charting literacy:  Here are errors from a good module RN.com has: Professional Documentation:  Safe Effective Legal.  (Students could make it into an alpha list or an acronym list). Most of these would be applicable for physicians as well as nurses. (You might want to make them positive: e.g. “Record Pertinent Health or Drug Information.”)

3d small person makes a tick in cell. 3d image. White background.

Common charting mistakes to avoid include the following:

  1. Failing to record pertinent health or drug information
  2. Failing to record nursing actions
  3. Failing to record that medications have been given
  4. Recording in the wrong patient’s medical record
  5. Failing to document a discontinued medication
  6. Failing to record drug reactions or changes in the patient’s condition
  7. Transcribing orders improperly or transcribing improper orders
  8. Writing illegible or incomplete records
from:  Nurses Service Organization, 2008, pp. 4 – 5

From a medical standpoint: Take a look at: Top 10 documentation error pitfalls: from Wisconsin Medical Society: 2008.

  1.  Teach with examples.  Show students excellent examples of charting to give them the necessary language for their work.  Give them criteria that facilitate effective charting.  Look back at the RN.com for some great criteria! As well CMA (Canadian Medical Association) has a good module called Medical Records Management with 31 (!) criteria for effective charting.

NOTE:  I’ve never met anyone who can keep to a 31 point checklist, but the criteria cited are all really important, so…perhaps students can check off the ones they think they do well already, and star the ones they need to work on.  A sampling of their work in clerkship (observation and feedback—still necessary) will demonstrate their self-assessment skills as well as how well they record.

10.  For senior clerks and residents: The  nursing module, RN.com: Professional Documentation:  Safe Effective Legal, has a list of situations that are classified as high stakes documentation.  This would be critical information for senior clerks and residents. (You’ll see that I’m citing nursing education here a lot: Nurse Researchers and Nurse Educators do excellent work on health and education.)

charts patient safety handover
For Residents and Senior Clerks

In Ratnapalan et al, Charting Errors in a Teaching Hospital, these suggestions for residency are included:

  • Many training programs recognize that residents in their first month may have charting errors and have put in place orientation programs, increased supervision from senior residents and staff, and a more thorough review of the notes that are written by new residents.
  • The ED at the Hospital for Sick Children is the only dedicated pediatric emergency department in the city of Toronto, and 380 to 400 trainees rotate through the department annually. Currently, there are orientation packages, orientation sessions, and a Web-based orientation available for trainees to teach accurate charting of emergency records.
  • The orientation package is a large binder with complete instructions on goals and expectations, codes of conduct, medical record keeping, handling of specimens, procedures, and academic activities.

Glad to get feedback on these strategies, and add to the list! What do you suggest?

send us your suggestions

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The Troublesome Ethics of Entrepreneurship in Medical School Admissions

Medical school applications are becoming big business, and a rather troubling expression of supply and demand economics.

The “demand” side consists of the many thousands of young people in North America engaged in the highly competitive process of applying to the limited number of seats available at publicly subsidized Canadian and American schools. Rebecca Jozsa, our intrepid Admissions Officer and I recently explored the “supply” side by carrying out a simple Google search of options available to the assist the aspiring medical school applicant.

For MCAT preparation, we found no fewer than 22 available courses (probably an underestimate). The “MCAT Ultimate LiveOnline 123-hour” experience is offered multiple times per year for $2,199US. For those who prefer more intense and more personal preparations, the “MCAT Summer Immersion” experience can be had for $9,499US, not counting, of course transportation and accommodation. The “Most Comprehensive Prep Course in Canada” runs over 10 weeks, costs $2,195, comes with testimonials from satisfied customers and features both instruction by successful students and “unlimited free repeat policy”. There are many other choices, a veritable smorgasbord of choices.

One can also opt for more comprehensive guidance through the entire application process. One group provides the following offering: “With our flagship service, we offer unparalleled quality that will make your application to medical school stand out”. In addition to “MCAT prep”, clients can opt for any or all of “Online Diagnostic”, “Comprehensive Application Planning”, “Application Review”, “CASPer prep”, “Interview Crash Course”, “Interview Preparation”, and “MMI prep”. Costs, understandably, vary based on individual preference and perceived need, but appear to range from a few hundred dollars for individual components to more comprehensive packages such as the Platinum bundle which goes for $3500US. It’s hard to get all the details as to what’s available without engaging one of the friendly “consultants” for a “personalized needs analysis” (which we declined) but the sky appears to be the limit in terms of costs. Some arrangements even come with money-back guarantees!

It’s clear from the advertising that many of these programs employ, or are even operated by, medical students or recent grads. Who, after all, would be in a better position to provide the “inside information” so essential to success?

So, is all this a problem?

On the one hand, all this is perfectly legal free enterprise. It’s addressing a perceived need, clients are fully informed and fully competent, no one is forced to engage these processes unwillingly. It could be argued that these programs allow very worthy and genuinely motivated young people to pursue their dreams and overcome many of the unintentional barriers that we all would acknowledge are inherent in the admissions system. One could argue that medical schools themselves have given rise to these business opportunities by making the MCAT such an integral component of the admission process, while at the same time dropping basic science prerequisites.

On the other hand, one must also acknowledge a number of potential concerns:

  • The widespread availability of these services may force students to participate to simply not be disadvantaged relative to other applicants. It’s no understatement to say that candidates feel desperate for any advantage in the process. That desperation, it could be argued, is being exploited.
  • This intensive preparation and rehearsing for the various application processes may result in candidates portraying themselves in an unrealistic fashion, thus subverting a process fundamentally intended to ensure applicants are appropriately suited to a career in medicine. Such “mismatches” can be disservice to all, including the applicant themselves.
  • These services are obviously expensive, adding a further socioeconomic barrier to medical education, a problem widely acknowledged in both Canada and the United States.
  • The involvement of medical students, as paid consultants or instructors is troubling. Their recent experience with the details of application processes, including the structured interviews (for which most schools require them to sign a non-disclosure agreement) makes them attractive for this role, but also sets up an ethical dilemma: Can they undertake to help applicants navigate their interviews without sharing information or insights they have acquired as a result of their own experience? Even if specifics are not explicitly divulged, it’s hard to imagine that their recent intimate involvement in the process won’t find its way into their “counseling”.

All this provides lessons and demands reflection on a number of levels.

For the aspiring applicant, perhaps a word of caution. The principle of “caveat emptor” (let the buyer beware) very much applies. There is no accreditation or credentialing process for these offerings. Applicants may not be getting valid advice. I’ve heard anecdotally from students who have been advised to avoid expressing any personal opinions and instead memorize and regurgitate the prepared responses to anticipated questions. Admission committees and interviewers, searching for sincerity and deep commitment to a career in medicine, are astute assessors and have become very attuned to the “coached” candidate. They will become even more vigilant. The sincerity and true commitment they’re looking for tends to stand out, and is very difficult to artificially manufacture.

This entrepreneurial phenomenon should also cause medical admissions committees to reflect on their processes. One has to question the validity of the MCAT as an assessment of scientific aptitude if an “immersion experience” is truly effective in influencing test results. Do we believe a background or interest in basic science is an important applicant characteristic? If so, do we feel successfully undertaking an MCAT prep course meets that criterion?

For medical students, entering a profession that is self-regulatory and rightfully expects high levels of personal integrity and accountability, opportunities to become involved in these programs pose perhaps their first personal ethical dilemma. Clearly, what makes them attractive to these agencies is not their personal counseling or teaching skills, but rather their status as successful medical school applicants, which brings considerable cachet and intimate knowledge which is of high value. They will find (as they will as practicing physicians) that their professional identity can’t be easily separated from their personal lives, and therefore puts them in an ethically ambiguous position.

In our society, it seems supply will always be found when demand exists and sufficient resources are made available. That this has extended to the medical school admission process should come as no surprise. However, it does raise some unintended, but nonetheless concerning consequences. As always, your views on this issue are most welcome.

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

 

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Year in Review? Why wait until then?

When I worked as a journalist (about a million years ago), an annual task was writing “Year in Review” articles. These were summary or “round up” stories with the highlights of the previous year.

The stated intent was historical record, reminders and reminiscing; marking highs and lows, significant events and momentous occasions. On a more practical level, these stories could be compiled fairly easily, mostly in advance, and take up copious column inches in our weekly paper in the week between Christmas and New Year’s when nobody was reading anyway and the editorial staff wanted to take extra time off from covering newer news. Closely tied to these were “Resolutions You Should Make Now!” advice columns.

With this cultural backdrop assigning retrospection to the turn of the year, it’s easy to become cynical about such things—and reduce thoughtful review to top-ten lists and cliché-ridden commentary. For educators, however, the importance of review should not be treated so lightly. Review and reflection are important. We expect our learners to do it. Educators should give it just as much attention.

Review and reflection are integral to effective teaching practice. January is a great time for this, but so is June, or September, or some other month. Right now, for some, a semester has recently ended, for others, it’s just beginning. There are benefits to both retroactive and proactive review – and in doing it more frequently than an annual check-mark on a to-do list.

So, instead of a ‘year in review’ summary, or even a list of new year’s resolutions for medical education, here’s a sample framework for incorporating review into your teaching practice. (Use it annually, or more often, as needed).

Theresa’s Five Step Review and Revise Process

Step 1: Review & Reflect

Whether you’re considering a whole course, a few teaching sessions, or a single seminar or other learning event the process is the same. Consider:

  • What happened? What worked? What didn’t? (If you’re forecasting: What could be some pitfalls? What am I worried about?)
  • For anything that didn’t go well, or didn’t accomplish what I planned: How can I fix it? (Forecasting: Do I have a back-up plan? Do I need one?)
  • What’s a manageable change? Do I have the knowledge, skills and ability to do this? Where can I get support and/or resources? (Forecasting: Do I have the resources I need? What kind of feedback could be helpful to me on my teaching sessions?)

 Step 2: Reconsider7916463

Once you’ve reflected on what’s happened, or what you have planned, consider:

  • Did I meet my objectives (or will my plan meet my objectives)?
  • Are there things I did (or I’m planning) that are just out of habit?
  • What should I change to make my course/session/seminar more engaging/relevant/appropriate?

 Step 3: Find Resources

When you revise your teaching plans, you may also need additional resources. This could be in the form of your own skills, materials, input from colleagues. Consider:

  • What support do I need to get to where I’d like to be?
  • Do I have the abilities to do what I plan? If not, how could I acquire the necessary skills?
  • Are there existing materials that could help me? Do I need to develop new materials? Who could help with that?
  • Who could I call on for support or assistance?
  • What sort of time frame do I have?

 Step 4: Refine your plan

Evauluation ChecklistSometimes, what we’d like to do just isn’t in the cards this year—there can be a lot of constraints on our teaching in time, materials, scheduling. It’s important to refine revisions into things that are manageable and realistic. Sometimes you are in a position to make large-scale changes to how you deliver your learning events, other times, not. Avoid the “all-or-nothing” plan: Incremental changes are better than no changes. It’s better to be good, than to be perfect. Consider:

  • How realistic is my plan?
  • Are there things I consider “must haves” and things that are “nice to haves”?
  • If I could only make one change in my teaching right now, what would it be?

 Step 5: Reflect & Review

At the end (or the beginning) – take another look. Good teaching really is an iterative process with the cycle of review, revision, redeliver.

Sometimes the best way to review and reflect (and plan) is to talk it out with a colleague. Bouncing around ideas can bring new perspectives and inspire you and others to add to your teaching toolbox. If you’d like to chat about your teaching any time, get in touch with the Education Team.

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Socrates, “pimping” and teaching in medical education

Recently, one of the words in the title of an article in Academic Medicine really caught my eye: “Socrates Was Not a Pimp:  Changing the Paradigm of Questioning” by Dr. Amanda Kost and Dr. Frederick M. Chen. (Kost & Chen, 2015)

Of course, the word that caught my eye was “Socrates,” he of sitting with students under an olive tree fame

20120223-Socrates Greuter

and, of course,  from Bill and Ted’s Excellent Adventure. socrates with bill and ted

Much of the scant information we have about Socrates is from his students, Plato and Xenophan.  Plato portrayed Socrates as an excellent teacher and questioner, in the Dialogues, where a series of questions is asked not only to draw out individual answers, but also to encourage fundamental insight into the issue at hand.

Can it be, Ischomachus, that asking questions is teaching? I am just beginning to see what is behind all your questions. You lead me on by means of things I know, point to things that resemble them, and persuade me that I know things that I thought I had no knowledge of.

–       Socrates (Quoted in Xenophon’s “Economics”) Portrait Herm of

Of course, I can’t deny that another word caught my eye in the title:  It’s not always that you see the word “pimp” in a medical education journal.

However, it’s a common term in medical education, since 1989 at least, where Brancati used it to refer to a questioning method that is supposedly Socratic but is defined as “whenever an attending poses a series of very difficult questions to an intern or a student.” (Brancanti, 1989) He suggests questions “should come in rapid succession and be essentially unanswerable.”  There are other definitions, and the “not a pimp” authors Drs. Kost and Chen, write that in these definitions the purpose of the practice is to reinforce the power hierarchy of the team and, more specifically, the attending physician’s place at the top. (Kost and Chen, p. 21)

In a 2005 study, by Wear et al. fourth year medical students were questioned about the practice of this form of questioning:

Students divided pimping into “good” and “malignant” categories. “Good pimping” actions included questioning that advanced or enhanced the learning process and also encouraged students to be proactive about their learning…“Malignant pimping” frequently employed techniques designed to humiliate the learner. All students in this study identified humiliation as an outcome of any type of pimping—even good pimping had a component of shame because of the public embarrassment of not knowing the answer.  (Wear, et al, 2005 cited in Kost & Chen)

I’d like to discuss “pimping” both from a syntactical and a pedagogical perspective.

I was trained as a language educator to acknowledge that language has a very pronounced impact on constructs in our thinking.  I have to admit that I don’t get the use of the term.  The other definition of pimp:  a person, especially a man, who solicits customers for a prostitute or a brothel, usually in return for a share of the earnings; pander; procurer (Online Dictionary and Merriam-Webster Dictionary) seems to have very little to do with questioning, whether benign, or malignant.

“Pimping” then… you know, that’s the last time I’m going to use the word! I dislike the relationship it implies that could so easily settle into the hindbrains of all us who have been using it.   With your permission, I’m going to try “hounding” instead.  Drs. Kost and Chen agree with me: “This word may evoke a negative affective response, and we would also argue that the use of such a derogatory term to describe an experience in medical education is unprofessional.”

Because, you see, questioning is one thing, and is an excellent and powerful educational tool.  However, when does questioning move into “hounding”? It happens when the questioner is pursuing a different goal than a pedagogical one:  perhaps humiliation(“She needs to know this stuff”), or going way beyond the knowledge of the level of the learner (“Shouldn’t clerks know this, or is it residents? Fellows?”) or venting frustration and anger (“You guys think you’re so smart? Well, let’s see…).  They include the well-known “Read my mind” type of question, and the question that is so obscure that very few know the answer (except perhaps the questioner?).

In the Wear study, students felt questioning  “was useful to “promote learning, logical thinking, defending one’s decisions, quick recall, self-assessment, and communicating well with one’s peers.”  They didn’t like the hounding part of it, and wanted to use volunteering answers as an alternate to centering someone out and hounding them. (I know, I know…this can be an important part of questioning…I hear you and I’ll come back to this.)

So, let’s get back to Socrates.  The Socratic questioning method is used often today, tho’ it appears it can be misunderstood.  In a recent vehement and lively DR-ED listserve discussion, the Socratic method was linked heavily with “hounding” by one participant.

Socrates used the dialectic method of teaching, whereby he assumed the role of someone who knew nothing about a topic, and drew the students’ ideas out, through a series of questions, each one probing more in depth or looking at different options. (Fun fact:  Did you know that the word “education” comes from the Latin ex ducere (to lead or draw out?)

The scientific method, which begins with a hypothesis and then proves or disproves the hypothesis is widely credited with having its roots in the Socratic method. just saying

Since Socrates was mainly concerned with students uncovering their own beliefs, and the validity of those beliefs, the correction of misconceptions and reliable knowledge construction all around large concepts such as truth and justice, modern teachers have created a sort of system for modern Socratic questioning of all types of learning.  Here are some of the characteristics:

1.    Students are questioned in a group, and in modern times, others in the group can collaborate with each other to find answers.  But not always…Socrates challenged his listeners and students.  And he picked them out, as well as had them volunteer.  But learners could help each other.  You’ll see in this sculpture, Socrates teaching in the Agora, by Henry Bates,  below how avidly everyone listens to each other.listening

2.    Socrates believed questioning would motivate learners and help them to the joy of learning. Thus, questioners should create a safe and comfortable context for questioning, where wrong answers are simply a signpost to heading down another path of learning.  In other words, they wouldn’t mind being centred out because they were enjoying learning.

3.  Use of by “why”, “what if” “how”, “then, if…” or open-ended questions vs. closed ended questions such as “What is this object?” “What is 1+1?” (Perhaps we can start with close-ended questions especially for novice learners, but they shouldn’t be the end goal of the questions.)

socrates and exams

3.  Socratic questions must be: 1) Interesting, 2) Incremental, 3) Logical (moving from the student’s prior knowledge towards a goal), and 4) Designed to illuminate particular points.

4.  Questions should be well-planned with a goal of benefiting the student at his/her learning level in mind.  Sometimes you have to start factually, but there should be progression toward critical thinking.

Let’s summarize, and then I’m going to prepare for you to write in to tell me what you think about “hounding” and questioning:

1.    Let’s not use that word again…it’s really ugly semantically.

2.    Hounding is not questioning.  Hounding is hounding and it’s not supported pedagogically. Questioning is an excellent way to teach.  It doesn’t have to be sweet, nor does it have to be easy.  It has to be respectful and with the appropriate underlying purposes.

3.    If we’re going to claim that “hounding” is Socratic, or even our questioning strategies are Socratic, let’s start using Socrates’ methods more.  Let’s aim for critical thinking questions, one of Socrates’ key purposes in questioning.i cannot make

4.    Let’s focus on our learners and tailor questions to their learning level.

5.    Let’s create a climate where questioning is accepted and even welcomed.  Let’s give our learners appropriate language to acknowledge they haven’t prepared, or are at the limits of their abilities thus far and need assistance.

In my next column (look for it in January 2016), I’ll provide more suggestions—based on Socratic principles—for keeping Questioning productive.

So, what do you think?  Are you a Socratic questioner?  Do you think hounding has a purpose?  Are there aspects of your teaching and questioning that can be enhanced through Socrates?

Looking forward to hearing from you about this.

And it’s not a smooth segue, but while I’m here with you, I’d like to take this opportunity to wish you all the best of the season!

seasons greetings

And here’s to great teaching in 2016!

 

 

References:

Brancati FL. (1989). The art of pimping. JAMA. 262:89–90.

Dictionary.com http://dictionary.reference.com/browse/pimp and Merriam-Webster Dictionary http://www.merriam-webster.com/dictionary/pimp

Kost, A.& Chen, F.E. (2015). Socrates was not a pimp:  Changing the paradigm of questioning in medical education. Academic Medicine, 90: 1.

Wear D, Kokinova M, Keck-McNulty C, Aultman J. (2005). Pimping: perspectives of 4th year medical students. Teach Learn Med. 17:184–191.

 

 

 

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It’s time to re-invent the Clinical Clerkship

FlexnerThe need to provide supervised learning within the clinical setting has always been regarded as essential to the development of future physicians. Indeed, early versions of medical education consisted entirely of what could only be termed apprenticeships under the direction of a fully- qualified physician who was engaged by the student as the tutor, mentor and assessor. It was largely as a result of Abraham Flexner’s (pictured) transformational 1911 review of medical education in North America that medical schools were required to provide formal instruction in the basic and medical sciences. However, Flexner continued to emphasize the critical role of learning with the clinical setting. This became consolidated into the discrete role that came to be known as the Clinical Clerkship.

group72Being a “Clerk” was to have a job or role within a hospital’s complex system of service delivery. The role consisted of “clerking” patients (carrying out admission histories and physicals), following the progress of patients through their hospital stay, arranging and following up on investigations, and coordinating discharge and post hospitalization follow-up. In addition, Clerks had unofficial but widely accepted service delivery roles of their own within hospitals, including phlebotomy, administering intravenous medications, performing simple procedures such as Foley catheter insertion, cast removal, simple suturing and recording electrocardiograms. Appropriately supervised and monitored, this role provided opportunities to engage patient care in all its complexity in a transitional fashion, leading eventually to more independent practice after graduation. The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today. Importantly, the role of the Clerk varied very little between services, specialties and differing patient populations, the goal being to develop strong foundational skills in patient assessment and management, which were felt to be consistent and “learnable” within any patient care context.

In short, being a Clinical Clerk was a job. Clerks had a widely understood and (dare we say) useful role within the hospital. As a Clinical Clerk, a medical student felt part of the service delivery because they were making a tangible contribution. They therefore felt, and were, valued.

Many factors have combined to, gradually and without deliberate intention, dramatically alter the role:

  1. The service components came to be recognized as excessive and non-educational, to the point of diminishing true educational opportunities. Accreditation standards confirm and reinforce this perspective.
  2. Our hospitals have become much more focused on efficient, focused, therapeutic management of patients with complex and critical diseases. Diagnostic processes, so important to the Clerkship learning experience, have largely shifted to the outpatient setting.
  3. Career selection and the CaRMS application process have become a major focus for our students, making multiple, shorter service assignments preferable to the longer, continuing assignments that allowed the Clerk to develop a clear role within service teams.
  4. Hospitals are much more regulated environments that require clear definitions of roles and scope of practice for all providing care.

Although these issues are all valid, one must now ask what price we’ve paid for this evolution. A few questions come quickly to mind, and are being asked by our students, faculty and hospital personnel on a daily basis :

  • What aspects of patient charting are Clerks expected to provide?
  • To what extent are Clerks empowered to write patient orders?
  • What diagnostic tests are Clerks empowered to order?
  • Is a Clerk permitted to submit a consultation request or requisition for an invasive investigation?
  • What medications can a Clerk prescribe, if any?
  • What procedures are Clerks expected to provide?
  • Can a Clerk obtain informed consent for procedures? If so, what procedures?
  • To what extent should a Clerk be expected to provide care for a patient in an emergency (arrest) situation?
  • In all these issues, what degree of supervision is required, and by whom?

Clearly, the application of all these aspects of service provision will vary between clinical assignments, but their fundamental nature (or, to use hospital terminology “scope of practice”) should be consistent throughout. It should not be necessary to re-define the Clerk role for every rotation.

Our Hospital Liaison Committee, capably chaired by Christopher Gillies with representation from all teaching hospitals, faculty, administration and students, has recently been considering solutions to the Learning Environment concerns described in previous articles (meds.queensu.ca/blog/undergraduate/?p=2026). They recognized that many of these concerns may have their roots in this lack of clarity regarding the Clerk role and have therefore advocated a redefinition of the role. To this end, our Clerkship Committee (Chaired by Andrea Winthrop and consisting of all Clerkship Course Directors) met this past week to re-define the role or “job” of the Clinical Clerk, recognizing our current educational requirements and current reality of the hospital based learning environment. They have already made excellent progress in addressing the various issues listed above.

To short, our senior medical students (Clinical Clerks) are able to make valuable contributions to patient care in the hospital environment. It is in doing so that they truly grow as physicians. That can only happen with a clearly articulated and widely accepted role description, appropriate to the modern hospital environment, developed jointly by medical education and hospital leadership.

 

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

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Students compete in 7th Annual Health Care Team Challenge

Three interprofessional teams of students faced off on Monday, November 16 in the 7th Annual Queen’s Health Care Team Challenge.

The teams tackled a case developed by the Health Service Centre team at Canadian Forces Base Kingston. Each team had students from Nursing, Medicine, Occupational Therapy, Physical Therapy and Psychology.

The five-member judging panel included two local clinicians who developed the case, along with faculty, student and patient representatives.

The teams had been preparing for the competition since October 16.

The winners were “Team Three”, which included:  Ahyoung Cho, Nursing; Wilson Lam, Medicine; Heather Shepherd, Occupational Therapy; Kayla Hertendy, Physical Therapy; Stephanie Gauvin, Psychology; Additional Team member: Elishea Mardling, Occupational Therapy; Back-up member: Verdah Bismah, Medicine; Faculty mentor: Lynne Harwood-Lunn, MN, RN, School of Nursing.

team three
The winning Health Care Challenge Team, shown here at the orientation event in October.

The two other teams were: Team One: Kyrinne Lockhart, Nursing; Alex Trajkovski, Medicine; Allie Rogers, Occupational Therapy; Heather Greene, Physical Therapy; Melissa Milanovic, Psychology; Additional Team member: Richa Kukkar, Physical Therapy; Back-up member: Shikha Kuthiala, Medicine; Faculty mentor: Brent Wolfrom, MD, School of Medicine. And Team Two: Charlotte Wilson, Nursing; Stephanie Piper, Medicine; Joshua Lee, Occupational Therapy; Erin Makins, Physical Therapy; Robyn Jackowich, Psychology; Additional Team member: Claudia Romkey, Nursing; Back-up member: Greg Smith, Physical Therapy; Faculty mentor: Heidi Cramm, PhD, OT, School of Rehabilitation Therapy.

Co-moderator Anne O’Riordan noted that all three teams’ presentations were exceptional, each presenting the case in a unique way which made for an educational evening for all.  Co-moderator Ralph Yeung was a member of the very first Queen’s team in 2009.

The Health Care Team ChallengeTM is an interprofessional education event, originally developed at the University of British Columbia in the 1980s. Students volunteer to participate in order to enhance and practice their collaborative team skills. Each student interprofessional (IP) team is provided with the same case to work on for a period of three weeks, with the goal of developing a collaborative, interprofessional person-centered plan of care. A faculty mentor is matched with each team for consultation and advice.

The Queen’s Health Care Team Challenge is jointly sponsored by the Faculty of Health Sciences’ Office of Interprofessional Education and Practice (OIPEP) and the Queen’s Health Interprofessionals Student Society (QHIP).

Team Three (soon to be renamed the Queen’s Team) will compete in the National Health Care Team Challenge™ in March 2016, hosted this year by Dalhousie University.

“Major Marlene Lefebvre was instrumental in connecting the health services team at the base with OIPEP, after initial email connections made by Alice Aiken,” O’Riordan said. “It really took a ‘health care community’ to do develop, organize, and implement this event and the learning was apparent for everyone.”

Here’s the beginning of the case the teams had to address:

You are a medical officer (MO, i.e. a military physician) in the health care team in Care Delivery Unit (CDU) 2 at 33 CFH Svcs C in Kingston, Ontario. The Base Surgeon (BSurg) informed the team yesterday the she was talking to the task force surgeon in Afghanistan and that an injured female service member would be arriving at the clinic this morning for an assessment. It will be sometime mid-morning before she arrives, hot off a CC-117 Globemaster transport aircraft landing in CFB Trenton at around 0730.

You don’t know much about the case other than that she is a 25 y.o. captain logistics officer who was injured two days previously in Cyprus, where she was undergoing a decompression stop after finishing her tour in theatre in Afghanistan. You note that she is a member of the Canadian Forces Joint Operations Support Group (CFJOSG) based at Canadian Forces Base (CFB) Kingston, and you remember that members of the unit were attached to a provincial reconstruction team (PRT). She is ambulatory as far as you know…

 

Credit where it’s due:

It takes a lot of effort from a great many people to pull an event like this together. In addition to the teams, here are the folks who made it happen:

Case Developers:

Health Services, Canadian Forces Base Kingston

CFB Kingston Liaison:

Major Marlene Lefebvre

Moderators:

Anne O’Riordan, OIPEP Clinical Educator, QHIP Advisor (OT)

Ralph Yeung, HCTC winner, 2009; IP Award of Leadership, 2013 (X-Ray Tech)

Welcoming Keynote Address:

Dr. Alice Aiken, Director, Canadian Institute for Military and Veteran Health Research, Queen’s University, Royal Military College, Kingston. (PT)

Judges:

Dr. Lucie Pelland (SRT) – Faculty Representative (PT)

L.Cdr. Bradley Stewart, Clinical Rep. (Medicine)

Capt. Dwayne Rennick, Clinical Rep. (Social Work)

Amanda Shamblaw, Student Rep., QHIP Exec., Past HCTC participant (Psychology)

Dr. Peter Dunnett, Community/Patient Rep. (Economics Professor, ret., RMC)

Official Timekeeper:

Chloe Hudson, QHIP Executive Member, Past HCTC winner (Psych)

Presentation of Team Certificates & Team Photos:

OIPEP & QHIP

Presentation to Winning Team:

Dr. Rosemary Brander, OIPEP Director (PT)

 

 

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