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

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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

 

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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