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.
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:
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.
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.
Mr. 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)
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.
Sir William Osler 1849-1919. A Selection for Medical Students. Edited by Charles G. Roland. Hannah Institute for the History of Medicine. Toronto.
“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.
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.
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.
Back 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.
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)
Undergraduate Medical Education
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)
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):
- 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.
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”.
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)
Undergraduate Medical Education
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).
- 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 firstname.lastname@example.org
Theresa Suart email@example.com
Student wins prize for project on physicians with disabilities
What started as a project for her Critical Enquiry class turned into an award-winning poster presentation for Kirsten Nesset of MEDS 2017.
Nesset attended the 24th annual History of Medicine Days Conference at the University of Calgary in March where she won Best Poster Presentation for “Physicians with Disabilities in Canada: History and Future”.
Classmates Elena Barbir and Sophie Palmer also attended the conference, presenting on their Community-Based Projects. The three received the Boyd Upper Prize, which is awarded to the Queen’s medical student or students who have conducted original historical research and then had the work accepted for presentation at a peer-reviewed meeting.
Nesset’s interest in the area of disability started at home, she explained in an interview.
“It was something I was really interested in because my father has a visual disability and he’s an engineer,” she said. “He lost his vision when I was about 10 – so I grew up with him adapting to that and his work making accommodations.” And this got her thinking.
“You don’t really see many people with visual or physical disabilities in medicine and I wondered what the accommodations might look like for them and what kind of policy might be in place if there was any,” she said. “I wondered what that looked like in Canada.”
She quickly discovered that there wasn’t much information readily available. “It ended up being a much more global project in the end because there’s very little research in Canada,” she said.
As her CE Mentor, Jacalyn Duffin, pointed out: “Her first discovery was that almost no one had published on that topic, although there was a robust literature on burnout, stress, addictions and other mental problems.”
“The absence of any historical predecessors meant that she had to do some original digging, to produce what is effectively the first history on the topic and to try to explain why the question has not been asked before,” Duffin added. “Her research involved searching the literature, news reports, and eventually interviews.”
“Although Kirsten’s focus was Canada, she discovered that a relative silence on physicians with disabilities pervades the literature in general, making her findings relevant well beyond our borders,” Duffin said.
Nesset has plans to continue research in this area. To start, she plans to interview some physicians through the Canadian Association of Physicians with Disabilities. “Some physicians have come forward to say they would be interviewed – because there isn’t a lot of narrative from Canada yet.”
She would also like to delve further into what medical schools list as technical requirements for graduates. “Part of my project was looking into admissions requirements and there’s nothing in those but there’s a lot of talk about meeting technical standards and technical requirements and each school approaches that differently,” she said.
As she is starting her clerkship rotations in the fall, Nesset is hoping to complete some interviews by the end of the summer, but sees this as a longer-term project.
“Realistically, this is something I’ll carry through the next year and hopefully finish up part-way through clerkship.”
One strong lesson from this project is that history does not necessarily mean antiquity or even a few hundred years ago, Nesset said. “From my experience, history can also be incredibly recent. I looked at history as of 1980, essentially, or 1975. Then up until now, which is why it’s titled ‘history and future’.”
“A history of medicine project doesn’t necessarily mean you’re looking far back in the past, it can be more recent and you can apply it to future considerations, for example for policy development,” she said.
We’d like to feature news about our students’ achievements at conferences such as this. If you have a suggestion for a student to feature in a future blog post, please email me at firstname.lastname@example.org. We’ll follow-up on as many as we can.
Thank you, Peter
The history of career counseling in our medical school divides nicely into three “eras”. Before 2006, students were informally supported through the efforts of faculty mentors, but there was essentially no structured program or standard approach. The next eight years or so can be rightfully dubbed the “Peter O’Neill Era”. Recruited to the role of Director, Career Counseling in July of that year Peter resolutely went about developing a program of individual counseling and innovative organized group activities that supported hundreds of students through the increasingly complex and stressful process of selecting and engaging a postgraduate residency position. He worked alone for much of that time, until joined by Dr. Kelly Howse about three years ago. As he steps down from that role this year and we enter the “post-Onellian” era of Career Counseling, it’s clear that he has provided our school with a very solid foundation to build upon.
The core of Peter’s approach and our current program is personalized counseling with attention to the needs of each student. That individual approach is enhanced with a series of information and orientation sessions that feature themes as diverse as CV preparation, how to dress and interview for success and how to navigate the CaRMS application process. Over the years, our students have had enviable success in the matching process, a testimony to Peter’s efforts. Kelly Howse has been able to build on the foundations Peter established, and is now leading the development of a national document on Career Counseling standards and best practice, which is rooted in many of the principles and practices Peter established.
I personally feel very grateful for Peter’s presence in our school. As a devoted Queen’s grad with experience in community practice before engaging his current specialty of Obstetrics and Gynecology, he brought a unique blend of personal dedication and practical “real world” perspective to his practice and teaching, as evidenced by numerous teaching recognitions through the years, including the very prestigious Connell Award and the Association of Academic Professionals in Obstetrics and Gynaecology of Canada (APOG) Educator of the Year Award. Moreover, he has always been willing to contribute and to serve, and I have certainly benefitted from his advice and support over the years. Although he’s moving on to another career role, I know he’ll remain dedicated to our school, and his life’s journey in education is far from complete.
What makes folks like Peter so very valuable to medical schools is really very simple: they truly and deeply care. That caring begins with their approach to the practice of medicine, but extends naturally to their students and their institutions. Great medical schools are built around such people.
Thank you Peter.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
June Curricular Leaders Retreat held: EPAs, Remediation and Feedback, oh my!
After bringing another busy semester to a close, UGME curricular leaders took time to reflect on the past year and take part in workshops and discussion groups on a number of areas of the curriculum at their semi-annual Curricular Leaders Retreat on June 19. The aim of the retreat was to share information and to generate ideas and solutions to address teaching and assessment challenges.
In his end of year report, Associate Dean Anthony Sanfilippo highlighted accomplishments of the past year as well as announced new faculty appointments.
After providing an entertaining and informative review of the process of curriculum renewal that UGME has undergone over the last several years, including the development of the “Red Book” objectives, Dr. Sanfilippo discussed how the emerging use of Entrustable Professional Activities (EPAs) will relate to and refine our existing curriculum and assessment processes.
Dr. Sue Moffatt presented an information session on how the three classroom-based “C” courses relate to both clerkship and the rest of the curriculum.
In a discussion about Service-Learning, led by Dr. Sanfilippo, faculty brainstormed ways additional service-learning opportunities could be created for medical students and others as well as ways they could support and encourage students in these endeavours. The Service Learning Advisory Panel will consider their suggestions and recommendations.
As a follow-up to last year’s popular workshop on remediation strategies, Michelle Gibson, Richard Van Wylick and Renee Fitzpatrick presented “Remediation 2” with additional cases and strategies.
For the afternoon, participants chose between a session on writing narrative feedback or one on making ExamSoft work for you.
Designed in particular for faculty working in clerkship, clinical skills and facilitated small group learning (FSGL), for the workshop on narrative feedback, Cherie Jones and Andrea Winthrop provided concrete examples and solutions to situations faculty routinely encounter when needing to provided constructive feedback to students. This included a discussion of ways in which oral and written feedback differ.
In the ExamSoft workshop, Michelle Gibson, Eleni Katsoulas and Amanda Consack worked with faculty to show how to tag mid-term and final assessments to match to assigned MCC presentations and Red Book objectives as well as coding for author and key word. Using these ExamSoft tools upfront makes it possible to use built-in reports to blueprint assessments, rather than having to do so manually. (For more on ExamSoft, check out the team’s poster from CCME at this link.)
To wrap up the day’s activities, pre-clerkship and clerkship course directors brainstormed with competency leads for ways the milestones identified for these intrinsic roles can be met throughout the curriculum. How to highlight and incorporate patient safety in different courses was also considered.
Documents from the Retreat are available to curricular leaders under “Retreats” on the Faculty Resources Community Page.
Bridging the gap between theory and practice in Medical Education: Entrustable Professional Activities.
Anyone who’s struggled through high school or university language courses will have observed, perhaps with exasperation, how young children learn to speak those languages quite effectively without the benefit of formal instruction. Growing children blissfully bypass linguistic theory and grammatical rules, and simply start speaking the language, employing a combination of imitation and trial-and-error to find what sounds and phrases produce desired effects. In fact, they may not even be aware that any linguistic conventions or grammatical structures exist. In my high school experience, French-speaking classmates had difficulty passing high school French courses because, as our non-Franchophone French teacher explained, the course was about the French language, not about speaking French. This distinction, lost on myself and the other peri-pubescent males of our rural Ontario community, caused many to abandon all hope for the educational system. There was a gap, it seemed, between formal “book learnin’” and real world skills that would allow people to function effectively and earn a living.
Every discipline, occupation or societal role can be regarded as requiring both theoretical underpinnings and practical application.
The theoretical components consist of the relevant knowledge base and a deeper understanding of the principles on which that knowledge base is established. This may involve learning scientific or abstract disciplines that might seem quite removed from the practical application. Such learning usually resides formally within our educational institutions and is recognized through the granting of diplomas or degrees.
Practical application, in contrast, is pragmatic, workplace-based and performance driven. Knowledge acquisition is more directly related intended purposes, and the ultimate goal is mastery of the specific skills, acts or functions understood to be requisite to the role.
The history of medical education is a story of struggle to balance theory and practice. Initially, medical education was purely a workplace, apprenticeship-based experience. Aspiring doctors worked with established practitioners and at some point, usually established by mutual agreement, were deemed ready to practice independently. The emergence of professional societies provided some external scrutiny and certification of competence. It was the rather profound intervention of the Carnegie Foundation and its sponsorship of the Flexner enquiry and subsequent report released in 1911 that moved medical education firmly into the university setting and established the requirement for fundamental education in the scientific foundations of medical practice.
Today, medical schools continue to struggle with establishing the appropriate balance between theory and practice. Educators ponder the degree to which fundamental science should be provided, the methods in which it should be taught, when and how patient-based experiences should be introduced. Students struggle to find “relevance” in their educational experience, particularly in the early years. A degree of mutual trust is essential to the process.
The emergence of “competency- based” education over the past decade or so is a valiant attempt to bridge the theory/practice gap. The “competencies” are based on the “roles” considered essential to (and characteristic of) the effective, practicing physician. In addition to expertise in clinical medicine and its scientific foundations, communication, collaboration, scholarship, advocacy, leadership and professionalism have been widely and rightfully accepted as attributes of the effective practitioner. Utilizing those attributes as a basis for development and design of a medical educational program may seem logical and appealing. However, on closer inspection, this extrapolation makes two key assumptions that are fundamentally flawed and have resulted in considerable challenges to our programs:
The first flawed assumption is that all competencies can (and should) be taught and learned. Many of the competencies relate to personal attributes, values or qualities. Examples drawn from our own competency framework include:
- The graduate is able to identify honesty, integrity, commitment, compassion, respect and altruism
- The graduate demonstrates respect for patient confidentiality, privacy and autonomy
- The graduate demonstrates respect for diversity, regardless of social, cultural or ethnic background
- The graduate demonstrates engagement in effective and shared decision making
Such objectives can be identified, characterized, used for purposes of selection and even required as a behavioural expectation. However, they are, for the most part, inherent characteristics that can’t truly be “taught”. It’s no more reasonable to expect that any individual can be taught to be a doctor than it is to expect than anyone can be taught to be a star athlete. Certainly good education can characterize the key expectations, contextualize their role and refine their application, but they cannot be developed de novo, regardless of good intentions, diligence and excellent teaching methods. Nonetheless, medical education programs devote precious curricular time and resources in attempts to ensure students possess attributes that, many would argue, should be substantially in place on admission.
The second flawed assumption is that all competencies can be reliably assessed. The medical education community has developed impressive expertise in the assessment of knowledge, skills and even complex tasks. However, the assessment of personal qualities such as interpersonal collaboration, compassion and integrity has not progressed much past the “know it when I see it” stage.
All this has led to a strong sense among both teaching faculty and students that there continues to be a “missing link”, essentially a theory/practice gap between the stated objectives of our program, and the fundamental goal of producing graduates able to excel as postgraduate program trainees and as young physicians.
To address these concerns, the medical education community is beginning to embrace an approach originally proposed by Dr. Olle ten Cate (ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005: 39(12); 1176, and ten Cate O. Trust, competence and the supervisors role in postrgraduate training. BMJ 2006; 333(7571);748).
“Entrustable Professional Activities” have been defined as units of professional practice. As such, they are tasks or responsibilities that trainees are to be able to perform independently by the time they complete their educational program. Importantly, EPAs are independently executable, observable, and measurable. In short, they go beyond what our students should know and be, and articulate in specific terms the things we expect our graduates to be able to do, and form the criteria by which they can be objectively and reliably assessed. The various competencies are necessary components required in order to achieve that EPA. However, demonstration of ability to perform the EPA, not the components, is the necessary final step to qualification.
To illustrate, let’s consider the simple and familiar example of driving a car, which can be considered a societal EPA. In order to achieve that EPA, candidates must master certain competencies, such as understanding the rules of the road, good vision, trustworthiness. Those attributes must be demonstrated or mastered in order to qualify to drive, but the ultimate “test” is the driving test itself.
An example of what might constitute a EPA for medical education might be the ability to perform a history and physical examination appropriate to patients presenting with certain key clinical presentations. That particular activity requires a number of requisite competencies including, for example:
- An understanding of the structure of the normal human body
- An understanding of structural changes that occur in various disease states
- An understanding of the symptoms and signs expected that are relevant to various presentations
- An understanding of the pathophysiologic mechanisms of clinical signs and symptoms
- An ability to communicate effectively with patients from various backgrounds
- The ability to maintain patient confidentiality
- The ability to interact effectively and respectfully with patients and their families
- The ability to understand the clinical utility and predictive value of various physical examination findings
- The ability to manage an interview effectively and efficiently
It becomes apparent from this list that medical expert, communicator, professional and scholar competencies are all required in order to carry out this particular, key EPA. They must all be learned and mastered individually, to be sure. However, individual achievement of each component is insufficient unless they “come together” to enable the learner to perform the fully formed professional activity.
Importantly, EPAs can be developed relevant to the fully qualified physician, and then described relevant to various stages of development. They therefore have the potential to unify the medical education continuum from entry to independent practice readiness.
A number of key organizations either have developed, or are in the process of developing EPAs. The American Academy of Medical Colleges sponsored an international consensus panel that produced a particularly attractive set of 13 EPAs currently being piloted at selected sites. The Association of Faculties of Medicine of Canada, at the suggestion of the Undergraduate Deans, has recently established a committee under the leadership of Dr. Claire Touche that is exploring the development of a common set of EPAs that could be utilized by all Canadian medical schools. The Royal College of Physicians and Surgeons of Canada, is incorporating EPAs as foundational component of it’s Competency by Design approach to postgraduate and continuing medical education.
In the meantime, our schools are likely to engage EPAs more actively as they endeavor to ensure their curricula are relevant to their students, and reliably address the real needs of postgraduate programs and society.
EPAs are the bridge that will take us from theory to practice.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education