It’s time to re-invent the Clinical Clerkship
The 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.
Being 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:
- 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.
- 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.
- 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.
- 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)
Undergraduate Medical Education
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.
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:
Health Services, Canadian Forces Base Kingston
CFB Kingston Liaison:
Major Marlene Lefebvre
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)
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)
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)
Why I can’t build an addition and the fall filing cabinet
This fall, I’ve been cleaning out closets and filing cabinets and purging, as they say on Houzz. I didn’t want to—I hoard my teaching materials as if they were gold. But, my husband said, “If you don’t get rid of some of this stuff, we’ll have to build an addition onto the house.”
I don’t quite know why that’s a bad thing…:) Teachers are packrats—you never know when you’re going to need something again to help students and other teachers.
However, apparently we can’t build an addition just for more filing cabinets. So, I’ve started cleaning out my notes on teaching from…well… I started teaching in 1980…
I’ve rediscovered some wonderful things, and I thought I’d share some with you. Here are a few from my filing cabinets:
- First of all for our students (and anyone else who reads): I found this poem by the late great poet Maya Angelou which actually a student drew to my attention years ago (a shout-out to Jessica Chiu formerly at OCA!). It’s about reading, and if there’s anything I know about UG medicine, it’s about the amount of reading you have to do. I hope you find lots of ideas sticking to your mind.
Popcorn leaps, popping from the floor
of a hot black skillet
and into my mouth.
Black words leap,
snapping from the white
page. Rushing into my eyes. Sliding
into my brain which gobbles them
the way my tongue and teeth
chomp the buttered popcorn.
When I have stopped reading,
ideas from the words stay stuck
in my mind, like the sweet
smell of butter perfuming my
fingers long after the popcorn
I love the book and the look of words
the weight of ideas that popped into my mind.
I love the tracks
of new thinking in my mind.
- More for students…and teachers using small group learning: Roles to Assist in Group Learning
Many medical students have told me about their horror stories of group work, either in high school or university. And it’s true…sometimes teachers throw students into groups without advice or support to work things out. Sometimes one student dominates the group; others are couch potatoes and hitch-hikers. Some block consensus, some goof around and still others withdraw. Bearing in mind our adult learners in medical school, and also the concept of self-directed learning, here are 20 (!) roles which students can adopt in groups. So even if a student is an introvert (see the book Quiet: The Power of Introverts in a World That Can’t Stop Talking), he or she will find some useful roles below. Teachers, you can encourage students by helping them see these roles in their work. (Thanks to my old bosses, Gray Cavenaugh and Ken Styles at the Ontario Ministry of Education. I’d forgotten how good you were!)
Students, practice putting yourself in each of these roles, think of others in the group, and begin developing your group leadership strengths. Teachers, when I used these with students in the past, I asked them to read them over and put a star beside the ones they do, and an exclamation point for a few they’d like to try.
Teachers, do you recall hearing that students learn best with this saying: Tell me; show me; let me try?
It’s actually the first thing I heard about (that I remember) when I hit Teacher’s College all those years ago. Here’s how I translate it into Medical Education:
|What it means||In medical school|
|Tell me: lecture or telling—even assigning reading especially with guides. Learners say, Get me oriented, motivated and let me absorb facts and concepts.||Provide students with facts, characteristics, vocabulary, symptoms, etc. through (mini-) lectures, or readings with questions attached, about medical conditions, systems, and approaches. Our RATs, or quizzes help students process what they’ve been told.|
|Show me: Learners say, Demonstrate how this works so I can see it in action. Give me examples of how it works!||Show students through written or verbal examples–cases you have encountered on how to recognize patterns, how to differentiate among diverse conditions, etc. Video clips and demonstrations are also really useful! A summary of your key findings and learning and the strategy of Think-Aloud (just what it sounds like) from the cases is useful for students to follow your thought processes. Don’t forget to tell them what you ruled in, and what you ruled out and why.|
|Let me try. Learners say, Give me a chance to apply the learning to see if I can do it myself, or if make it work in different situations.||· Provide students with written or verbal cases through which to work, often with a partner or in a group, so that they can learn how to apply the facts and examples you have given them.
· Change up the circumstances: paediatric or geriatric patient; chronic conditions vs. acute conditions, co-morbidities, different presentations or similar presentations with different associated conditions, different points in the illness journey.
· Put students in a simulated learning environment—such as with standardized patients.
· In clerkship, under supervision, allow clerks to apply their learning to patient care.
Key here is to find out if the students have learned through their application (mid-terms, graded team assignments, individual assignments) and observe them in practice (MiniPEx, MiniCEx, field notes, etc.).
So three tips from the files. I found a few more 🙂 Stay tuned…
Have a great fall! I’m looking forward to continuing the dialogue about teaching and learning.
We write these blog articles with ideas, thoughts and strategies, usually for teachers, but often for students too.
We’re always interested in your thoughts, so please feel free to respond.
What’s in your filing cabinet?
Using Copyrighted Images in an Educational Setting: A Primer
By Mark Swartz, Copyright Specialist
Understanding a few of the basic concepts behind Copyright law can help explain why some images can be used in certain situations and others cannot. The most useful concept to consider when thinking about how images can be used is balance.
A Balancing Act
In the landmark Supreme Court case Théberge v Galerie d’Art du Petit Champlain Inc, Justice Ian Binnie characterizes Copyright Law with the following statement:
The Copyright Act is usually presented as a balance between promoting the public interest in the encouragement and dissemination of works of the arts and intellect and obtaining a just reward for the creator.
When you create a work, whether it is a book or an article, a photograph, a painting or any of the other types of expression covered by copyright (Copyright Act, RSC 1985, c C-42, s 5 retrieved on 2015-10-16), you automatically get a bundle of exclusive rights to that work. These rights include the right to copy, to distribute, and to assign your rights to others. The full sets of rights that you get are listed in the Act (Copyright Act, RSC 1985, c C-42, s 3 retrieved on 2015-10-16). And, while these rights are exclusive, they are limited in both time and scope. The balance between exclusive rights and limitations ensures that creators are fairly compensated for their work, while still allowing for some permission-free uses in ways that contribute to the public good.
Limitations to the exclusive rights of copyright holders include the following:
- Copyright protection does not last forever. In Canada, the general rule is that Copyright lasts for 50 years after the death of the copyright holder. After that point, the work will fall into the public domain and can be used for any purpose.
- The Copyright Act lists a number of situations where Copyrighted works can be used with permission from Copyright holders. These situations are called exceptions. The most well-known exception is called the fair dealing exception, which allows for some use of copyrighted material, as long as the use falls under one of the purposes listed in the Act, and if the dealing is fair (Copyright Act, RSC 1985, c C-42, s 29.1 retrieved on 2015-10-16).
If you have determined that you are using a copyright protected image, you need to get permission from the copyright holder or you must ensure that your use falls under one of the exceptions in the Copyright Act.
So what does this mean if I want to use images in my class?
There are a wide variety of exceptions that apply to the use of copyrighted images in a closed, educational setting like a classroom or a Learning Management System. In the classroom, there is an exception that permits the reproduction of copyrighted images for use in PowerPoint presentations on campus (Copyright Act, RSC 1985, c C-42, s 29.4 retrieved on 2015-10-16). Additionally, fair dealing and the publically available materials exception will allow for the inclusion of many images in PowerPoint slides uploaded to Learning Management Systems like MEdtech. For more information, please see the In the Classroom and the On the Internet sections of the copyright and teaching section of my website.
As for images used in student assignments and presentations, most of the images used by students are likely to fall under the fair dealing exception. I do, however, always recommend that students do their best to find copyright free (or suitably licensed) images, so that when students leave the university and are asked to use images in the workplace, they know how to find images that can be easily used without having to get permission. Suggestions for finding these types of images are available on the Resources page of the copyright and teaching section of my website.
What about using images in materials that I post to the open web? What about images in conference presentations, posters and in research projects?
When you move from a closed environment like a Learning Management System to an open environment, it becomes more difficult to rely on exceptions like fair dealing, particularly if you intend to use your work for commercial purposes at any point.
In these situations, I would avoid using copyright protected images without permission and instead rely on finding works that are either licensed through the Creative Commons or that are in the public domain. The “resources” link I included in the section above provides some resources for finding these types of images. Images used in conference presentations and posters are much more likely to be fair than those on the open web, but I would be careful posting these presentations and posters on conference websites.
Finally, most images used in research projects and theses are likely to be fair dealing. One complication is that if you are going to publish in a traditional journal or publication, it is likely that the publisher will require that you get permission for everything. Fair dealing is often perceived to be too much of a risk for these publishers, so, if you are going to go that route, make sure you find materials where permission can be granted easily or is not required.
This is just a brief overview outlining some of the main image-related considerations that you might come across as an instructor or researcher. If you have any further questions about the use of images, please get in touch with me at extension 78510 or at email@example.com.
Théberge v. Galerie d’Art du Petit Champlain inc.,  2 SCR 336, 2002 SCC 34 (CanLII), <http://canlii.ca/t/51tn> retrieved on 2015-10-16.
Copyright Act, RSC 1985, c C-42, s 29.1 <http://canlii.ca/t/52hd7> retrieved on 2015-10-16.
Accreditation Success Stories…and lessons going forward.
Medical school accreditation has been described, with some justification, as the colonoscopy of medical education. The parallels are rather striking:
- Both require a long and distinctly uncomfortable period of preparation.
- Both require a public exposure of personal features most would prefer to keep modestly hidden.
- Both can get messy.
- Both carry high potential for embarrassment.
- In both cases, the procedure itself can be tortuous and painful.
- And finally, for the asymptomatic and fundamentally healthy, their value is highly debatable.
Also like colonoscopy, one emerges from a successful examination with a sense of great relief. That relief, in part, is simply related to having completed the process. Doing so with a successful report of findings adds immeasurably to that sense of relief.
At Queen’s, we are fortunate to have recently emerged from our own collective internal examination with that great relief, having achieved a full eight year approval, with no further invasive procedures required until 2023.
Reflecting now on a process that really started after our last review in 2007, it’s possible (and probably healthy in a preventive sense) to set aside for a moment the struggles and various deficiencies that required attention, and focus rather on the positives that have emerged. A few come particularly to mind and merit attention because they bear important messages we should carry into the future.
Firstly, our success was based on our ability to mount a common effort. Without question, the very real threats to our school imposed by the 2007 review galvanized our efforts and collective will in a way that made possible the changes that we needed to make.
Our Deans (both Drs. Walker and Reznick), engaged accreditation efforts with resolve and unconditional support. Our university leadership (particularly Principal Woolf whose first duty in his new role was to publicly defend a medical school he had just inherited), have been staunch supporters of the accreditation effort. Our Department Heads, to a person, have been nothing but supportive of the school. Our curricular leadership, undergraduate office, medical education team, medical technology unit, hospital partners and, critically, our students, all came together to meet the various challenges, and did so with methodical efficiency, driven by a shared desire to support (dare I say, defend) our school. One sees such common, focused effort only rarely, and usually only when necessitated by great and imminent peril. It is nonetheless rather inspiring to consider what our common efforts achieved and speculate on what might be possible if we could continue to work collaboratively without the need for external motivation.
Secondly, one must acknowledge that many significant and enduring changes emerged from these efforts. A robust and effective new curriculum, effective assessment methodologies, creative and updated approaches to teaching, a revised and much more effective governance structure, a refurbished framework of policies and procedures, our highly impressive and sought after MedTech curricular management system, and even our new School of Medicine Building itself were all, at least in part, motivated or accelerated in their development by our accreditation efforts.
The process brought welcome attention to a number of areas of strength within our school, often overlooked as we focus attention on problem areas. Refreshingly, and unexpectedly, the recent report made reference to our teaching, which it identified as an area of strength. To quote from our report:
As reported by students in the ISA [Independent Student Analysis] and by the survey team, the program benefits from many capable and dedicated teachers. For example, in the MEDS 125 [Blood and Coagulation] course, with 99% of students commenting on the course, no negative comments were made within the 9 pages of comments, and the survey report suggests that the Course Director and the faculty involved in this course are to be congratulated…. Another course that received similar accolades was MEDS 127 [Musculoskeletal], where the team reported: “Dr. L Davidson who continually monitors and enhances the course. This is a “poster child course” and Dr. Davidson deserves significant recognition for the evolution of this highly innovative and interactive course.”
In fact, we are truly blessed with many dedicated and talented teachers, knowledgeable and committed faculty leaders in all key portfolios, committed and hard working undergraduate administrative and educational support teams, and a receptive and engaged student body.
In the final analysis, the most enduring lesson we should take away from our eight-year struggle with the accreditation process must be that we never again require a “crisis” to spur us to collective action in order to ensure we are providing the very best educational experience for our students. Complacency is poison. The continual, collective pursuit of quality improvement and courageous innovation must be our continuing goals. These are the lessons of the day.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
When is an hour only 50 minutes?
This blog post is part of the series of periodic updates from UGME committees.
Have you looked at your teaching or learning schedule recently? You know those hour-long and two-hour long blocks? They’re a bit misleading.
We’ll admit it, we’re part of the problem since we routinely talk about hour-long and two-hour-long classes. The reality, however, is that our class blocks are really divided into 50 minutes for class and 10 minutes for a break. If you’re teaching a two-hour block, that first 10-minute break can be a little flexible about where it lands, but for finish times, it’s vital to stick to the end at 20 minutes past the hour rule.
What are those 10 minutes for? That’s actually time for the next instructor to get set up, so they’re ready to start on time. Time for folks to grab a coffee or hit the washroom – or check their Facebook or email. It’s also the 10 minute traveling time from room to room. This hasn’t always been much of an issue for our medical students, but it’s more important than ever as we cope with the classroom disruptions because of the flood in the Medical Building in August. Often, our students are now moving between farther-flung campus buildings for back-to-back classes – those 10 minutes are golden.
If you’re concerned about how to plan your lecture or SGL or other learning event with timing in mind, get in touch with the Educational Development team. We’re happy to help with plotting out sufficient flexibility so you can finish on time without missing out on essential instruction. (Email Theresa Suart at firstname.lastname@example.org)
The Curriculum Committee recently approved the TLIC proposal to map a series of “Integrated Threads” through the UGME curriculum. Integrated Threads represent important domains of learning for medical students that span multiple courses, terms and academic years. These may represent disciplines (e.g. genetics, geriatrics, imaging, pathology), competencies (e.g. communication, leadership) or other defined groupings (e.g. patient safety, diversity) which contribute to the attainment of the skillset of a graduating physician.
The aim in mapping Integrated Threads is to clearly articulate where particular topics occur and re-occur through our curriculum. It will help guide both learners and instructors in expectations and achieving learning objectives. Some integrated threads have an “anchor” unit within a course with other related material taught elsewhere throughout the curriculum (for example: Genetics). Others don’t have an identified unit, but are taught in relation to other material throughout the four-year UG program (for example: Imaging).
The inaugural Integrated Threads list – also approved by the Curriculum Committee – includes 28 distinct topics. Over the next academic year, TLIC will be working with faculty and the Education team to map existing curricula and identify opportunities for enhanced teaching of each topic. The Integrated Threads list will be reviewed on an annual basis.
The TLIC will keep you posted as the Threads are identified and mapped. Faculty who would like to suggest additions to the Integrated Threads list should contact the TLIC Chair, Dr. Lindsay Davidson (email@example.com) or the Educational Development team.
Tony’s Top Ten Tips for Success and Happiness in the Clinical Clerkship
This week, the class of Meds 2017 begins their Clinical Clerkship. This is a highly significant milestone in their medical education, representing not only the half-way point, but also a transition from a program dominated by knowledge and skills acquisition carried out in classrooms and simulation settings, to “real life” learning in a variety of clinical placements and elective experiences. Last Friday, this occasion was marked by a White Coat Ceremony, conducted by Drs. Armita Rahmani and Sue Moffatt, and featuring personal presentations and “pearls” from Drs. Heather Murray, Andrea Winthrop and Dean Reznick.
Top Ten lists have become ubiquitous, including those providing unsolicited advice for medical students. In fact, a quick Google search revealed no fewer than 76,200 such compilations, ranging from the authoritarian to the humourous. Undeterred, I offer my own list, all based on more than a few years of experience and observation as to what works and what sometimes goes wrong. So, here goes, in no particular order…
- Show up, and show up on time. It all starts with dependability. Even the most brilliant among us are useless if absent or unreliable. On the other hand, there will always be a welcome for the honest, steady contributor. If you are late, apologize, and do not show up with the coffee or snack that you picked up on the way.
- Repeat after me: “I don’t know”. Self-awareness is right up there with dependability. There will be things you don’t know. There will be things nobody knows. You will not get into trouble or lessen your reputation by admitting to a lack of knowledge or experience with a particular clinical situation or procedure. After all, you’re a medical student, you’re not supposed to know everything! You do need to know what you don’t know. You will have major problems if you compromise a patient’s care through your unwillingness to admit limitations.
- Make it your business to learn about things you didn’t know first time. In fact, become an expert in that issue and look for opportunities to apply your new knowledge. When you do, you’ll find it intoxicating, and will search out even more knowledge. Careers have been built on less. Regard every patient and fresh problem you encounter as your curriculum. Keep track. You’ll be amazed at what you’ll be learning, and how fast.
- Remember that no decision that’s made honestly and in the patient’s best interest can be wrong. Anything we recommend for our patients, even the simplest decision, test or therapeutic intervention must meet one of three (and only three) criteria – it must relieve symptoms, improve functional capacity or increase life expectancy. There is no other justification for any intervention. You can’t be wrong for trying honestly to achieve one of those goals.
- And yet, things can go wrong... Even the best and most obvious decision may not go the way we intend or hope for. When things do go wrong and patients suffer adverse outcomes, it must be openly acknowledged and understood to ensure everyone (including you) learns from that outcome and becomes a better provider. As a medical student, you will not be the responsible party, but are nonetheless in a position to learn. Don’t be afraid to engage such situations, and don’t hesitate to discuss your feelings and reactions with more experienced people.
- Ask questions. Not to impress or stand out, but because you really want to know, and are concerned about the impact on your patient. Ask respectfully, but don’t be afraid to challenge decisions. Good clinicians don’t mind being asked to explain what they’re doing. Really, they don’t.
- Get along. With everybody, not just those you think are important. Do this all the time. Everyone you encounter knows more about the practical aspects of health care delivery than you do. They all have something valuable to pass along if you’re attentive and receptive. I’m going to use a key word here: Humility. People can sense it and respond positively to it. The opposite is arrogance, which people can also sense but respond to quite differently.
- Eat, sleep, laugh. You’ll be busy, but not so busy that you won’t have opportunity to look after your own well-being. Use your down time wisely. Plan meals and recreation. Surround yourself with people who know you well and have the capacity to make you laugh. They will become increasingly precious to you. Talk to them.
- Be open to possibilities. If you think you’ve decided on career choice, don’t be shocked (or worse yet, disappointed) if something unexpected emerges. If you feel strongly conflicted, there’s probably a good reason. Talk it out with someone and remember it’s never really too late to change. If you can’t decide because everything seems great, that’s a good thing, but you might also need to talk it out. We’re available.
- And finally… look after each other. You know each other very well, and will know when someone is having difficulties, likely before they know it themselves. Don’t be afraid to reach out, or to seek advice or help. Our Student Affairs staff, headed by Dr. Fitzpatrick, Janet Roloson and myself are all available to you or your colleague. Remember QMed Help, the red button available on MedTech.
So there you have my list. Happy to receive revisions, additions or comments from readers. Final word to our students – enjoy. Clerkship is a great time to grow and learn.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Museum of Health Care event to highlight “Medicine in the Making”
Medical artefacts from the Museum of Health Care will be on display in the Grand corridor of the new Medical Building on Friday, September 25 from 9:30 a.m. – 2:30 p.m.
UGME Associate Dean Anthony Sanfilippo and Dr. Susan Lamb (adjunct assistant professor of history of Medicine) will be on hand over the lunch hour.
Curated by Museum of Health Care staff and QuARMS student Chantal Valiquette as part of a summer service project, “Medicine in the Making” is open to all to attend.
Summer School for Surgical Skills:
More student directed learning
About a month ago, we published the first installment in a series of articles we’ll be providing over this academic year featuring student directed learning that’s occurring in our school. We heard at that time of Alyssa Louis’ exploration of aerospace medicine. This week, I’ve asked Meds ’16 student Riaz Karmali to report on behalf of a group who have worked together and collaborated with faculty to develop a special learning experience in practical surgical skills. Riaz adds some personal perspectives based on his own experience with a medical student fellowship at the MD Anderson Cancer Centre.
Stepping from Idea to Reality: My Experience with the Surgical Skills and Technology Elective Program (SSTEP)
Only a handful of medical schools in North America have structured surgical bootcamps available to pre-clerkship medical students. Two summers ago, the Surgical Skills and Technology Elective Program (SSTEP) was piloted at Queen’s for second year students. This 2-week simulation-based program is designed to build technical skill and prepare students for the operating room. Participants practice suturing, vascular anastomoses, bone fixation, local skin flap design, and nasogastric and chest tube placement amongst other procedures in the surgical skills laboratory. The inaugural program had 22 participants and ran again this summer with increased faculty support and expanded simulation workshops.
How did SSTEP, an entirely student-led initiative, transform from a progressive educational idea into a sustainable program? The success of any early-stage venture, like a high-stakes horse race, is based on two players: the idea itself (the horse) and the team behind it (the rider). Jennifer Siu, Daniel You, and Stefania Spano were the “instigators.” As driven students, outside-of-the-box thinkers, and great team players, they developed a comprehensive proposal and pitched it to Queen’s faculty. Thankfully, they allowed me to come along for the ride. The goal was to prove that SSTEP was worth its $10,000 budget, faculty time commitments, and use of surgical training and laboratory resources.
The SSTEP curriculum has both a didactic and hands-on component integrated into each day. It was eventually tailored to align with clerkship learning objectives. The idea is to provide students with a non-threatening academic environment where they can practice with up-to-date surgical simulation technology. Students can also be able to explore their interest in surgery and surgical subspecialties. In addition, they can receive guidance from senior medical staff and take advantage of a low faculty to student ratio. The curriculum went through multiple iterations before faculty and administration approval.
But how do we know that SSTEP actually builds technical skills? The concept of hands-on instruction in a simulation-based laboratory accelerating the acquisition of technical skill is intuitive. I had experienced this as a first year medical student. I won a summer research fellowship to MD Anderson Cancer Center in Houston, Texas where my project required me to learn basic microsurgery techniques. In the laboratory, I started out with silicon tubes and progressed to arteries and veins in a live rat. However, I was disappointed that I could not quantify my improvement.
Naturally, we then decided that SSTEP participants should complete an Objective Structured Assessment of Technical Skill (OSATS) before and after the program. It was mandatory to complete a 12-minute basic suturing station in order to track skill acquisition. This research was particularly important given our cost-sensitive healthcare environment that is increasingly dominated by outcomes assessment.
Outside of technical skill, SSTEP also develops surgical knowledge, confidence, and career interest. With the guidance of our supervisor, Dr. Paul Belliveau, we created a written test (partly adapted from Principles of Surgery Royal College Exams) and exit survey to measure these outcomes directly. Our results were accepted to the Association of Surgical Education (ASE) and Canadian Conference on Medical Education (CCME). Jenn and Dan recently presented at the CCME. Hopefully, our experience with SSTEP can be a template for other medical schools interested in launching a pre-clerkship surgical boot camp. At Queen’s, we punch above our weight!
Outcomes of SSTEP:
→ The SSTEP written exam had a maximum test score possible of 73 and students scored significantly higher on the post-test compared to the pre-test (52.1 5.9 vs. 35.8 6.5 p =0.01)
→ Participants showed an increase in technical skill:
→ At the end of the program, 50% of participants said they considered a new surgical subspecialty while 72% of participants reconsidered elective choices
→ SSTEP was recommended to fellow pre-clerks by 100% of participants
→ Comparative and long-term analyses of SSTEP outcomes will continue with subsequent generations of the program
Looking forward, new “disruptive” ideas and technologies will continue to change the way medicine is taught and practiced. The mobile web, big data, robotics, and accelerated drug development are just a few domains where we have seen an unprecedented explosion of investment. Therefore, it is important that the next generation of physicians be dynamic thinkers that can anticipate future challenges and meet them with relevant experience. Any venture that improves the way we take care of a patient, treat disease, or deliver therapy is well worth the successes and failures that go along with it.
I would like to thank the leaders of SSTEP, Jenn, Dan, and Stefania, for bringing me onto their team. I would like to thank Dr. Belliveau for his support with the research study, Dr. Reznick, Dr. Rudan, and Dr. Sanfilippo for their dedication and wisdom, Ms. Kim Garrison for help with the surgical skills lab, Dr. Winthrop for curriculum development, Dr. Leslie Flynn and Bill Leacy for their financial expertise, all of the residents and faculty facilitators, and the amazing support staff who made SSTEP possible!
A vastly expanded number of practice options are now available to our students. At graduation, they are faced with a choice between no fewer than thirty direct entry postgraduate training programs. Providing opportunities to explore career options and to tailor their learning experience has therefore become a common and major objective of both students and medical schools. Working with our students, building on their imagination and initiative, is proving to be a winning strategy.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
A tale of two sports, a 7-year-old, and how we train doctors
By Michelle Gibson, MD, MEd, CCFP
Director, Year 1
Director, Student Assessment
Fall is a time of transition in many ways. In the land of Undergraduate Medical Education, our 4th year students are facing up to the joys and pains of the CaRMS process, our 3rd year students are anxiously and excitedly contemplating starting clerkship, our 2nd year students are returning to class as experienced students, and we have a whole new crop of 1st year students arriving to engage our curriculum.
In my main job (co-parent to a 7-year-old), it’s the time of year when soccer finishes, and skating starts up (and, of course, the fun and perils of Grade 2 must be addressed).
In the land of 7-year-old sport, as skating is about to start, there is a certain dread that I once again have to bundle up on a beautiful fall day to stand in a cold arena listening to (at times) dreadful music that we know will be played over and over all year long. The 7-year-old adores skating, though, and looks forward to each new ribbon or badge, and a report card outlining the skills he has acquired over the year. These are proudly displayed in his room. He jumps at every opportunity to skate, including in the middle of a heat wave in August.
While the outdoor soccer venue is generally much nicer for parents (except when we get to encounter Kingston’s weather extremes), it is, for me, fraught with frustration about how my child is supposed to learn soccer, which is a universe away from the approach in skating.
This year, I vowed I would try to be analytical about the differences (versus getting frustrated and emotional, which is the natural parenting reaction), so as to help my kiddo, who really, really likes soccer, but who gets upset because he can’t play as well as he would like, and can’t figure out why.
In soccer, the theory seems to be that if you find someone who knows how to play soccer, and they volunteer to show kids how to play, kids will learn—even if the much-appreciated volunteer has been given no guidance about how to teach the eager young Padawan. In practical terms, in our experience, this has meant having the kids do drills for 30 minutes, and then having the kids play a game. Somewhere in there, they are supposed to learn soccer. The skills are simple, right? You just run, and kick the ball. How hard can that be?
I have been to about 90% of the practices & games, and I have only rarely seen the kids being shown how to do something. My child has never been taught how to approach a game, even at a very basic level, except that he knows the point is to get goals. He knows that he should pass the ball and he generally understands why this is a good idea, but since he can’t quite figure out how to get the ball passed to him, this is not very helpful at present.
The boy can kick a ball, of course, and he improves a bit yearly, but no one has shown him how to control the ball at soccer practice. Fortunately for us, he loves soccer, and despite all of this, he plays with enthusiasm but not much skill. Other kids have real skills—possibly because their parents were actually taught how to play soccer, so they teach them, or, because they had different coaches over the years. As the boy ages, he gets more and more aware of the skills differential, and doubt is starting to creep in.
Contrast this to skating. From the first day of his first skating class (with the same child:coach ratio), he was taught HOW to skate, by a certified coach. There was a nice clear list of skills he needed to master before moving up a level. In pre-skate, one key skill is getting up from the ice. (I like that one in particular.) Having moved up to the “real” skating lessons, he works on different skills at three different stations at each lesson. As he masters the skills in any one station, he will get a ribbon, and move up a level.
My child responds to this, and so, having also been born with reasonably good balance, he has moved up the levels quickly, often skating with older kids. Some skill sets are harder for him, so he might be working on level 5 in ‘agility’ but only level 3 in ‘control’. Anytime he struggles with a skill and he can’t work it out himself, a coach will spend a few minutes watching him and then working with him on the skill. Each group has a teenaged program assistant who also helps show the kids how to do the skills. The report card we get each term has this all laid out for us, and we as parents can help him to know what skills he should work on (spirals, anyone?) to complete his current level.
The parallels to medical education are obvious to me. My medical education, and my clerkship in particular, was much very similar to the soccer approach: here’s some basic info, now go out there with practicing physicians, who have likely never learned how to teach, and, well, absorb it all and figure it out. If you found a resident, or other clerk, or a nurse who could show you how to do something, or who would explain why something was being done, it was a golden day. I don’t think this was very different than what most clerks of my era experienced.
Now, I will admit I learned a lot, and, I dare say, I was a good clerk—most of the time. My friends and I banded together, and taught one another. We passed on tips as one of us exited a rotation and the other one started. I definitely remember those days of not knowing what to do, being told to do it, and then not knowing why or how to do it. It wasn’t pretty. Some rotations were worse than others.
Skating lessons are much more in line with competency-based education. Our medical students crave clear directions, and clear instructions. The expectations are high but achievable, if they are clear, and feedback is provided. For some students, it’s easier (but never easy), and they are fortunate, and still deserve good teaching, assessment and feedback so they can improve. Other students really benefit from more explicit descriptions of what is expected, and feedback about what they need to do to meet these expectations. In my experience, most students welcome clear, high, but achievable expectations, in a supported environment. Learning medicine will never be easy, but we should not make things harder by just dropping them into an environment and hoping they figure out how to get the clerkship ball, so to speak. A few minutes of direct observation can help me determine where a student is struggling, and I can provide feedback—something I am (mostly) comfortable with, having benefited from many hours of faculty development and good mentors.
As we enter fall, the boy’s soccer medal has joined his collection, and he is anxiously awaiting the beginning of skating in a few weeks. I am not looking forward to the hours in the cold rink, but I know my frustration level will be significantly decreased. I’ll be ready and happily working with all the students in our curriculum, but I’ll work hard to ensure that our new clerks, in particular, do not feel like a somewhat lost soccer player in the middle of a field, knowing they want to be there, but not actually knowing where the ball has gone.
Welcome to clerkship, #QMed2017. I look forward to seeing you on the wards, and remember to have fun!