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.

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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…

  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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)
Associate Dean,
Undergraduate Medical Education

 

 

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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.

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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.

SSTEP

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.
Practicing basic microsurgery techniques but unable to quantify improvement.
Practicing basic microsurgery techniques but unable to quantify 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.
Screen SParticipants completing an OSATS before and after SSTEP to track outcomeshot 2015-09-14 at 9.16.55 AM
Participants completing an OSATS before and after SSTEP to track outcomes
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!
The inaugural SSTEP Class of 2014
The inaugural SSTEP Class of 2014

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)
Associate Dean,
Undergraduate Medical Education

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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.  kids' soccer

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 skating Lessons2skill 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!

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Introducing Queen’s Meds 2019

In late August and early September each year, the university seems to reawaken as returning students repopulate the campus. Our medical school curriculum is one of the first to get underway and, this past week, we welcomed members of Meds 2019, the 161th class to enter the study of Medicine at Queen’s since the school opened its doors in 1854.

meds2019

A few facts about our new colleagues:

They were selected from the largest applicant pool in recent memory – 4669 highly qualified students submitted applications last fall.

Their average age is 23 with a range of 19 to 31 years, with almost equal numbers of men and women (51% women, to be exact).

They hail from no fewer than 46 communities across Canada, including; Ajax, Ancaster(2), Aurora, Bowen Island, Brampton, Brantford, Calgary(2), Cambridge, Campbellton, Coquitlam(2), Courtice, Elora, Gormley, Guelph-Eramosa, Halifax, Kanata(2), Kelowna(2), Kingston, Lasalle, London(2), Markham, Midland, Mississauga(6), Newmarket(2), North Vancouver, Okotoks, Orillia, Orleans, Ottawa(10), Pembroke, Pickering, Richmond Hill(7), Rosseau, Scarborough(5), St. Catharines, Thornhill (2), Thunder Bay, Toronto (19), Trenton, Vancouver, Vaughan, Victoria, Virgil, Waterdown, Windsor (2) and Winnipeg (2) .

Seventy-six of our new students have completed an Undergraduate degree, and twenty-seven have postgraduate degrees, including five PhDs.  The average cumulative grade point average achieved by these students in their pre-medical studies was 3.77.  Their undergraduate universities and degree programs are listed in the tables below:

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An eclectic and academically very qualified group, to be sure.

At their welcoming session they were called upon to demonstrate commitment to their studies, their profession and their patients.  They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers.  At that first session, they were welcomed by Mr. Jonathan Krett, Asesculapian President, and Dr. Rene Allard, who provided them an introduction to fundamental concepts of medical professionalism. Over the course of the week, they met curricular leaders who will particularly involved in their first year, including Dr. Michelle Gibson (Year 1 Director) and Dr. Cherie Jones (Clinical Skills Director). They were also introduced to Dr. Renee Fitzpatrick (Director of Student Affairs) and our excellent learner support team, including Drs. Kelly Howse, Susan Haley, and Susan MacDonald, who oriented them to the Learner Wellness, Career Counseling and Academic Support services that will be provided throughout their years with us. They met members of our superb administrative and educational support teams led by Jacqueline Findlay, Jennifer Saunders, Amanda Consack, Kate Slagle, and first year Curricular Coordinator Corinne Bochsma.

Dr. Jaclyn Duffin led them in the annual Hippocratic Oath ceremony. Dr. Susan Moffatt organized and coordinated the very popular and much appreciated “Pearls of Wisdom” session, where fourth year students nominate and introduce faculty members who have been particularly impactful in their education, and invite them to pass on a few words of advice to the new students. This year, Drs. Erin Beattie, Jaclyn Duffin, Jay Engel, Renee Fitzpatrick, Jason Franklin, Michelle Gibson, Mala Joneja, Steve Mann, Alex Menard, Terry O’Brien, John Smythe, David Taylor and were selected for this honour.

They met and were greeted by Dean Richard Reznick who welcomed them and challenged them to be “restless” in their pursuit of personal goals and advancement of the profession.

On Friday, the practical aspects of curriculum, expectations of conduct and promotions were explained by Drs. Michelle Gibson and Richard Van Wylick. They were welcomed to our Anatomy Learning Centre and facilities by Drs. Steve Pang, Conrad Reifel and facility manager Rick Hunt, and participated in the annual memorial service with a moving dedication by University Chaplin Kate Johnson.

Their Meds 2018 upper year colleagues welcomed them with a number of formal and not-so-formal events. These include orientations to Queen’s and Kingston, introductions to the mentorship program, and a variety of evening social events which, judging by appearances the next morning, were much enjoyed.

For all these arrangements, flawlessly coordinated, I’m very grateful to Rebecca Jozsa, our Admissions Officer, and second year President and Vice-President Jonathan Krett and Monica Mullin.

I invite you to join me in welcoming these new members of our school and medical community.

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The Making of a Closer

Roberto Osuna is a closer.

The term “closer”, in this case, refers to a person who has a critical, very specialized, and highly visible position of responsibility on a baseball team. These folks are called upon to come into the game at the most critical juncture, when the outcome is very much in doubt, and are entrusted with ensuring that all the hard work accomplished by their teammates in establishing a lead is completed by striking out the last few opposition batters. As the closer goes about his task, he stands alone, the focus of attention. His teammates, managers, the opposing team, forty or so thousand people in the stadium and millions of people viewing, are transfixed in attention to every move. If successful, there is great jubilation, and he emerges as a hero, at least for today. If he fails, it is with great public exposure and he bears the burden of responsibility for the loss.

OsunaMr. Osuna has an uncanny way of engaging this role with cool and detached resolve. He is very successful, performing at the highest level, on a professional baseball team, in the midst of a highly scrutinized playoff race.

Did I mention that he’s 20 years old?

 

All this begs the question: what allows anyone to engage and excel in such a role, much less someone so young? An obvious answer is that Mr. Osuna is blessed with the ability to throw baseballs with prodigious velocity and accuracy. While certainly true, this fails to capture the entirety, or even the essence, of what’s required. There are many professional pitchers whose skills match those of Mr. Osuna and yet are ineffective in the closer role. How many of us, if magically endowed with the ability to throw the 97 mph fastball, would be able to do so effectively in the highly stressful setting Mr. Osuna faces on a regular basis? The physical skills, it would seem, are essential but not sufficient. There’s something about the attitude and personal qualities of the individual that enable him to translate these innate skills to success in his chosen occupation.

Recent attention in the press to Mr. Osuna’s dramatic emergence sheds some light (references below). Growing up in a poor coastal city in northern Mexico, quitting school at age 12 to work harvesting crops to support his family, practicing and playing baseball in the evenings, competing in leagues far away from home against men much older than himself in Mexico, Japan and the United States, overcoming language issues and, just last year, undergoing and rehabilitating from major elbow surgery, are all evidence that he has packed much life experience into his 20 years. He himself attributes his success to his family support and deep religious faith. He displays self-awareness and perspective well beyond his years: “I don’t think I deserve anything. But I try to do the best I can, get ready each day and be ready inside the stadium and outside too. I know where I came from and where I want to go.”

LaTroy Hawkins, a veteran relief pitcher who has seen his own share of adversity and began his career before Mr. Osuna was born, provides these insights regarding his new teammate: “I’ve always said, guys who are from rough areas, they’re comfortable being uncomfortable…Pitching in the big leagues is nothing compared to living where I did. Trying to live and survive in the inner city…that’s stress.”

In “Aequanimitas”, William Osler’s 1889 valedictory address at the University of Pennsylvania, he describes “imperturbability” as an essential attribute of the successful physician, and defines it as “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril”….“it has the nature of a divine gift, a blessing to the possessor, a comfort to all who come in contact with him.” He goes on, however, to describe how a “mental equivalent to this bodily endowment”, which he terms equanimity, can be characterized and cultivated by the student physician.

This week, a hundred of Mr. Osuna’s contemporaries began the study of Medicine at our school. They’ve been selected partially because they’ve demonstrated that they possess the academic equivalent of the 97 mph fastball. As with Mr. Osuna, their career success will be determined by much more, by an array of personal qualities also considered in the application process, Osler’s “imperturbability” among them. Their medical education will be as much about developing equanimity and those “mental equivalents to the bodily endowments”, as about acquiring factual knowledge and skills – a truth as relevant in our time as in Osler’s.

 

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

 

Thanks to Meds ’16 student and former Aesculapian Society President Carl Chauvin who shared with me some key insights that contributed to this article.

http://www.theglobeandmail.com/sports/baseball/blue-jays-rookie-reliever-roberto-osuna-thriving-on-the-games-biggest-stage/article26041351/

http://www.thestar.com/sports/blue_jays_baseball_blog/2015/08/blue-jays-bullpen-latroy-hawkins-says-roberto-osuna-has-it-factor-.html

http://www.thestar.com/sports/bluejays/2015/08/10/blue-jays-roberto-osuna-pitching-well-beyond-his-years.html

Sir William Osler 1849-1919. A Selection for Medical Students. Edited by Charles G. Roland. Hannah Institute for the History of Medicine. Toronto.

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“When you wish upon a star…” Alyssa’s Journey

When you wish upon a star
Makes no difference who you are
Anything your heart desires
Will come to you.

From: Pinocchio (1940), Walt Disney Pictures. Sung by: Cliff Edwards

The idea of allowing students to determine and design their own educational experiences may seem counter-intuitive to many, including students themselves. It’s certainly not easy to implement. However, setting aside the initial reaction and obvious practical issues, what eventually emerges is the realization that this is an approach with potential to bring out the best in the motivated student, extend the educational experience far beyond the traditional paradigms, and model the sort of life-long learning we’re hoping to ingrain in all our students.

“Self-directed learning, in its broadest meaning, describes a process in which individuals take the initiative with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying resources for learning, choosing and implementing learning strategies and evaluating learning outcomes.”  (from: Knowles, M. S. 1975. Self-directed learning: A guide for learners and teachers, Prentice Hall, Englewood Cliffs, New Jersey).

For those who require further convincing, I’ve asked Alyssa Louis, one of our Meds ’16 students to provide a guest blog this week. With the help and cooperation of Clerkship Director Andrea Winthrop and assistance of Clerkship Coordinator Jane Gordon, Alyssa arranged to undertake a rather unique elective experience during her Clerkship, pursuing an interest (perhaps “dream” or “obsession” would be better descriptors) she’s had for some time. As you’ll see as you read on, that pursuit has been very valuable and promises to pay huge dividends as her very promising career unfolds. And so, in Alyssa’s words…

Everyone I’ve worked with, spoken to or passed quickly in a hallway in the past 6 months has heard, at least on a few occasions, about my upcoming aerospace medicine elective. I was over the moon with excitement and probably made a few too many bad puns. However, before I launch into my personal experiences, I should explain that Aerospace Medicine is a sector within occupational health and preventative medicine that aims to preserve the health, safety and performance of individuals involved in air and space travel. Specialists, also known as “flight surgeons” must also be experts in delivering care in extreme environments, as many analog training missions occur at deep sea, high altitudes, remote deserts and polar locations.
This past July I participated in the Principles of Aviation and Space Medicine short course offered by the University of Texas Medical Branch (UTMB) as affiliated with the National Aeronautics and Space Administration (NASA.) The course, which is offered to final year medical students, residents and practicing physicians is run by UTMB faculty, many of whom have held the impressive titles of NASA flight surgeon or are acting medical directors for commercial space companies such as Virgin Galactic and Space Adventures.
In order to understand the unique health considerations for astronauts, we learned the basic physics and physiology of launching into space. Given that our millions of years of evolution selected human traits for life in earth’s gravitational field, it is truly remarkable that humans are able to adapt to life in space. Some of the many physiologic stressors include high G-force exposures of launch and landing, exposures to microgravity, galactic and solar radiation, circadian disruptions, noise exposure, carbon dioxide exposure, stress and isolation.
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Twice flown astronaut and physician Dr. Michael Barratt gave us an overview of the physiologic adaptation and maladaptation to spaceflight, including the important responses of the neurovestibular system, caudal fluid redistribution, blunting of autonomic responses, and of course the concerning loss of bone density and muscle mass. In order to counteract this loss, astronauts aboard the international space station train for approximately 2 hours every day. The challenge of creating weight-bearing exercise in a weightless environment is achieved with bungee straps and vacuum cylinders, which make for a surprisingly high fidelity training experience. Though I had worked up a fair appetite, I was not able to sample the “just-add-water” nutritionist-designed and astronaut approved freeze-dried shrimp cocktail or steak in a pouch.
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We received the historical perspective on aerospace medicine in a lecture by Dr. Charles Berry, a NASA flight surgeon during the Apollo and Gemini missions. At the tender but not subdued age of 92, Dr. Berry certainly did not withhold his objections to his Hollywood portrayal in Apollo 13. I got to sit in Dr. Berry’s old desk at mission control, the very same room where the moon landings were directed.
blog65-img3Back on earth, Aerospace Medicine also encompasses health maintenance and medical flight certification of airplane pilots. There is a truly complex relationship between pilot health and safety, and as we learned first hand in the full motion flight simulator, even perfectly healthy medical students can have vestibular mediated spatial disorientation leading to fatal crashes. We also learned the physiologic effects of airplane decompression, and its impact on time of useful consciousness through an altitude chamber run to 7620 metres (25,000 feet.) I thought fleetingly of Dr. Moffat’s respiratory physiology lessons as we reached atmospheric pressure of 276mmHg and my O2 saturation plummeted to 63%.
Now that I’m back home at Queen’s, I am looking forward to continuing to share my experiences with the rest of our community. I was extremely pleased to learn from a fellow tricolour, Queen’s emergency medicine graduate Dr. Christian Otto who is currently acting as a United Space Research Association principal investigator for the ocular health project with NASA. I will remain deeply grateful for the opportunity to blend my passions for medicine and physiology at environmental extremes. Of course, none of this would have been possible without support from Dr. Winthrop, Dr. Hollins, Jane Gordon and the UTMB faculty. Thanks Queen’s!
Did you know that…
  • Aboard the ISS, the sun rises every 90 minutes. And you thought your on-call room was a bad place to get a decent night sleep! In fact, one of the major challenges being addressed right now is circadian rhythm modulation for crew health.
  • CPR is very challenging in space because classic compressions would essentially push the operator across the room rather than pump the patient’s heart. The current literature suggests that the most efficient delivery is in the handstand position with feet braced against the ceiling.
  • Above 19.2km (63,000 feet) above sea level, the boiling point for water is approximately 37 degrees Celsius. One individual who survived exposure to this pressure described the feeling of saliva boiling off his tongue. Full pressure suits are required for survival above this altitude.
  • Astronauts train for their space walks in a massive swimming pool called the neutral buoyancy lab. There are mockups of the ISS underwater for astronauts to practice repairs.
  • Aboard the international space station, the main source of potable water is recycled urine. This water is used for drinking and rehydrating freeze-dried meals.blog65-img4
  • The current price tag to visit space as a commercial spaceflight participant is approximately $20 million dollars. This would not be covered on the average line of credit. The first Canadian to do so was Guy Laliberte, co-founder of Cirque du Soleil.

Medical school should be a place where students not only learn the “knowledge, skills and attitudes required of a physician”, but are also inspired to grow individually, gain self-awareness, pursue their own goals and develop their particular talents and interests in a way that will allow them to make unique, unanticipated contributions to society and to the profession. Alyssa’s story is a great example of what can happen when we work together with our students to go “outside the box” and make the extra effort to make the difficult and unconventional possible. When they “wish upon a star”… we’ll find a way.

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

 

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Get to the point with Ask-Tell-Ask feedback

By Theresa Suart & Eleni Katsoulas

 

Giving and receiving feedback effectively is a key part of the UGME curriculum. It’s also key in nearly every workplace, which could explain why there are so many different frameworks and recommendations for feedback “best practices”. Some of these are more effective than others.

Have you heard of the feedback sandwich? It’s one of the more popular feedback techniques and involves “sandwiching” negative or constructive feedback with two pieces of positive or complementary feedback. It’s also sometimes known as “PIP” for “praise, improve, praise”.

 

The idea behind this is laudable – cushion the blow of negative feedback and reassure the individual that they are doing some things well.

 

In practice, however, it’s fraught with difficulties, making it not very useful for the person receiving the feedback. Think about it:

  • I’ve just received two pieces of praise and one of criticism or a suggestion for improvement: what should I focus on?
  • The negative feedback is about something I did today, the positive things were from last week – the positive stuff must not be as important.
  • Two pieces of praise and one of criticism – guess that I’m mostly doing well!
  • The last thing they said was praise – must be doing great!

 

Writing in Harvard Business Review, Roger Schwarz also points out the fallacies of this approach. Schwarz notes leaders who use the sandwich approach to negative feedback do so for a variety of reasons. These include:

  • Thinking it’s easier for people to hear and accept negative feedback when it comes with positive feedback.
  • Assuming the sandwich approach provides balanced feedback
  • Believing giving positive feedback with negative feedback reduces discomfort and anxiety.

 

Schwarz then debunks each:

  • Easier: Most people on the receiving end would prefer to skip the sandwich – get to the point.
  • Balanced: Saving up positive feedback to sandwich negative feedback undermines timely delivery of the positive feedback. As Schwarz points out, research shows that feedback, either positive or negative, “is best shared as soon as possible.” He also asks: “Do you also feel the need to balance your positive feedback with negative feedback?”
  • Reducing anxiety: “The longer you talk without giving the negative feedback, the more uncomfortable you’re likely to become as you anticipate giving the negative news.” Meanwhile, the person on the receiving end “will sense your discomfort and become more anxious.

 

The UGME Education Team advocates the use of a new feedback sandwich replacing “praise, improve, praise” with Ask – Tell – Ask. This method was brought forward by Dr. Ayca Toprak and Dr. Susan Chamberlain, adapted from French, Colbert and Pien (ASE April 24, 2015)Feedback ata graphic

 

 

 

The ATA Feedback Model is similar to the traditional feedback model as it has three parts. After that, it’s quite a bit different. Using Ask-Tell-Ask, the Preceptor asks the learner for their input, then the preceptor tells them their impressions, then wraps up by asking the learner to help develop an improvement plan:

 

Ask – Tell – Ask

  • Ask the learner for their perceptions about strengths and challenges
  • Tell them your impressions backed by observations, and specific examples
  • Ask them what can be improved and how– assist you in developing a learning plan

 

Examples of topics to discuss (referencing objectives of the rotation, course, or activity):

  • Professionalism
  • Functioning in the team context
  • Skills (communication, technical, clinical)
  • Clinical Reasoning
  • Record keeping
  • Process or Content (knowledge or the way they use the knowledge; application of knowledge).
  • Background knowledge (this is knowledge of the discipline, scientific foundations, knowledge base).

The ATA model helps preceptors focus the discussion while scaffolding self-regulation and self-assessment. It also avoids the mixed-messages of the feedback sandwich approach.

The ask-tell-ask oral feedback is best paired with written narrative feedback. Watch for a blog post on this topic in September.


 

We used PowerPoint slides from a presentation prepared by Sheila Pinchin and Eleni Katsoulas, with slides from Cherie Jones, to prepare this blog. We thank Sheila and Cherie for their contributions.

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Are we forcing our students to choose between Learning and Success?

As the father of four sons, I have found that thought-provoking, articulate conversations with 17 year-old males are rare and remarkable occurrences indeed. Nonetheless, I was fortunate enough to have just such an experience this past week.

It all began when I came upon an article by Kristin Rushowy that appeared on the front page of the Toronto Star on July 19th describing the accomplishments of four young people who had achieved the highest averages among Toronto public high school graduates. A quote from one of these young scholars particularly drew my attention. It’s important, he said, to “follow your passion for knowledge, and not your passion for success”.

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Image Credit: Toronto Star July 19, 2015 [i]
Never having thought of these as mutually exclusive entities, I was intrigued enough to call the source of this comment, Elias Hess-Childs who had managed to attain an average of 99.5%, as had fellow graduating students Michael Nuh, Albert Loa and Sarah Tang. Turns out Elias is an engaging young man who not only knows his way around a high school curriculum, but has some rather prescient views about the educational process and is not at all hesitant to expound on them. He finds the attainment of high grades a “shallow” way to go about educating oneself and strives for deep understanding rather than simply achieving high grades. He is attracted to “interesting” courses and teachers rather than “bird courses”. Like the other students quoted in the article, he finds studying and memorization to be tedious, and largely unnecessary if one has achieved a true understanding of the subject matter. When asked what he finds most difficult, Elias tells me that conceptual and “qualitative” material such as history to be more challenging than the sciences (presumably that’s what dragged his average down to 99.5), but nevertheless plans to challenge himself with social science courses at university next year. A confident and self-aware young man with a bright future, to be sure.

However, there’s a somewhat more troubling side to the “learning versus success” concept. Notwithstanding students like my friend Elias who are able to achieve both, are our young people really being required to make this choice? Are they sacrificing their interests in order to ensure they attain great marks? Are they focusing on short-term retention and exam results rather than deeper, conceptual learning? Is all this diminishing what should be a time for open exploration and discovery? Perhaps most concerning, to what extent are those of us involved in higher education responsible?

Without question, our young people are growing up in an increasingly pragmatic and competitive world. Universities, graduate schools and professional schools such as Medicine are all utilizing academic achievement as a major component of their entrance criteria and, in fact, proudly publish the average scores of their entering students as a marker of excellence. High school marks, entrance examinations such as the MCAT, LSAT and SAT in the United States, are taking on great importance and threaten to indelibly categorize our student into those destined for “success” and those who must content themselves with alternatives. The educational process has, for many students (and, importantly, their parents), shifted from a process of discovery and enlightenment about themselves and the world, to a proving ground in which they must demonstrate their aptitude and competitiveness for future opportunities. And all this is happening during their formative teenage years.

This is further complicated by the inconsistency in high school academic standards that has occurred since the discontinuation of common examinations, and the gradual mark “inflation” that continues to occur. Medical schools, for example, face steadily increasing numbers of applicants with steadily increasing average marks, and diminishing band-width within those marks. Are young people truly getting a little smarter each year, or are high school examiners succumbing to the perhaps understandable desire to provide their students and schools competitive advantages?

One of our recent graduates, Dr. Julianna Sienna, has an interest in the topic of admission equity and a way of poking my conscience from time to time. She recently sent along a fascinating review entitled “Who Gets to Graduate?” that appeared recently in the New York Times Magazine (http://www.nytimes.com/2014/05/18/magazine/who-gets-to-graduate.html?_r=0). In that article, author Paul Tough reviews efforts undertaken at the University of Texas to address the issue of low graduation rates. Although drawn from an American context, the issues they describe certainly resonate and seem entirely relevant to the Canadian scene.

Among the many interesting points raised in that article, a few are particularly relevant to this discussion:

  • High school marks and entrance examination results have a powerful and enduring effect on self-image and sense of “worthiness” for various universities, programs and, by extension, career options.
  • Lower family income and having less well-educated parents are factors associated with lower graduation rates, even for students with similar entry grades and SAT scores.
  • Students with more modest marks and SAT scores, particularly those from poorer socio-economic backgrounds, tend to “undermatch” meaning, in the words of the author, “ they don’t attend or even apply to the most selective college that would accept them.”

To help underachieving students succeed, educational leaders have found that it is necessary to do more than simply deal with their financial and academic issues. “You also need to address their doubts and misconceptions and fears. To solve the problem of college completion, you first need to get inside the head of a college student”. The good news is that a number of innovative programs, focusing on dealing with adversity, building confidence and promoting inclusion are showing definite signs of success where traditional remediation streams and less demanding “developmental” courses were failing and, in fact, only perpetuating the sense of inadequacy.

To summarize, early academic performance during these formative years is a hugely powerful determinant of self-image and confidence, particularly when coupled with socioeconomic circumstances that reinforce the impression, but (and this is a big “but”) does not necessarily exclude young people from eventual academic success comparable to higher-performing entry students.

So what are the messages for those involved in the selection, education and career success of our young people? Certainly we should be celebrating the success of young scholars like Elias, Michael, Albert and Sarah and providing them post-secondary programs and environments in which they can continue to flourish and realize their considerable potential. However, we also need to recognize that not all students are in a position to take full advantage of our educational programs, that our evaluative processes at the high school and university level are far from precise, and that many very capable students with much to contribute to society may be discouraged or lost in the crowd. Our entrance processes should actively search for such students by going beyond the simple ranking of marks and explore more broadly the personal attributes, experiences and life goals of our students. Expecting that a young person will have demonstrated his or her career potential by the end of high school, and using our educational systems as competitive proving grounds is unfair to our students and a disservice to a society that benefits from the broad education of all its members. We can, and should, do better.

 

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

[i] http://www.thestar.com/news/investigations/2015/07/18/torontos-top-students-say-they-dont-study-that-much.html

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Bringing things into focus: Using focus groups to collect feedback

By Theresa Suart & Eleni Katsoulas

Amongst the plethora of student feedback we solicit about our courses, you may wonder why we sometimes add in focus groups. What could be added to the more than a dozen questions on course evaluation and faculty feedback surveys?

The information we gather in student focus groups doesn’t replace the very valuable narrative feedback from course evaluations, rather, it allows us to ask targeted questions, clarify responses and drill down into the data.

Developed from “focused interviews” around the time of the Second World War, focus groups emerged as a key qualitative research tool in the latter half of the 20th century. Robert K. Merton, a sociologist from Columbia University, is hailed as the “father of the focus group.” (He died in 2003 at age 92.)

Merton used focused interviews to gain insight into groups’ responses to text, radio programs and films. Politicians and marketing companies soon seized upon focus groups to gauge voter and consumer trends. The Queen’s UGME Education Team uses focus groups in a targeted way to augment information gleaned from course evaluation feedback, course director’s meetings with academic reps and other feedback tools.

According to a briefing paper from Carnegie Mellon University, focus groups are “particularly effective” for eliciting suggestions for improvement. “They are also much more flexible than surveys or scales because they allow for question clarification and follow-up questions to probe vague or unexpected responses.” It also helps that faculty rate focus groups as “accurate, useful and believable”.

If you’re asked to participate in a focus group, only agree if you think you have something to contribute to the investigator’s project or purpose. (Sure, it’s fun to come for the free food, but be prepared to contribute in a meaningful way).

groupe-discussion2-1What you can expect when you take part in a focus group:

  • To be informed if the focus group is for research or curricular innovation (or both). Research studies must have approval from the Research Ethics Board and require specific paperwork to document informed consent. Curricular innovation focus groups are less formal, but will still respect confidentiality of participants. These might not have the same paperwork.
  • The facilitator to set the ground rules, and guide the discussion. Savvy facilitators will do this with a minimum of fuss: they will listen more than they speak. (But you can certainly ask for clarification if you’re not sure of a question).
  • A co-facilitator will likely take notes and monitor any recording equipment used. The co-facilitator may summarize after each question and solicit further input as required.
  • You’ll be asked specific questions, and engage in conversation with the other participants.

What you shouldn’t expect:

  • A venting session. This isn’t the time to just complain. A focus group is looking for constructive feedback and suggested solutions.
  • To always have your say: the facilitator may realize they have reached saturation on a particular question and will move on. This is to respect your time. (You’ll have an opportunity to send additional comments electronically afterwards if you felt there is an important point that was missed).

What you can do to prepare:

  • If the questions are provided in advance (this is best practice but not always possible on tight timelines!) you should take some time to think about them.
  • Be sure you know where the meeting room is, and arrive on time.

What you can do during:

  • Contribute, but make sure you don’t end up dominating the conversation. The facilitator will be looking for a balance of views and contributors.
  • Listen attentively to others and avoid interrupting. The facilitator will make sure everyone has a chance to contribute – you’ll get your turn.

What you can expect from data collected at a focus group:

  • It will be confidential. Different strategies are employed. For example, you may be assigned a number during the focus group and participants asked to refer to people by number (“Participant 2 said…”).
  • In a formal research study, you should be offered an opportunity to review the data transcript after it is prepared. (This is sometimes waived on the consent form, so read carefully so you can have realistic expectations of the investigator).
  • The end product is a summary of the conversation, with any emergent themes identified to answer the research questions.

What you can’t expect:

  • A magic bullet solution to a challenge in a course or class.
  • One hundred percent consensus from all participants – you can agree to disagree.
  • For all outlier opinions to be represented in the final report. These may be omitted from summary reports.

We’re always grateful to our students for donating their time to our various focus group requests throughout the year. These contributions are invaluable.

If you think this type of data collection could be useful in your course review and revisions, feel free to get in touch. It’s one of the tools in our qualitative research toolbox and we’re happy to deploy it for you as may be appropriate.

Eleni Katsoulas eleni.katsoulas@queensu.ca

Theresa Suart theresa.suart@queensu.ca

 

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