Month: December 2014
I find myself writing these words on the day of the winter solstice. The days that have been getting progressively shorter and darker stop doing so, and now begin to slowly lengthen and become brighter. The derivation of the word “solstice” is itself interesting, stemming from the latin sol (sun) and sistere (to stand still). It’s therefore a time when all nature stops, pauses, and changes direction.
Over the years, the solstice has had considerable and variable significance, ranging from providing scientific insights about our position in the universe, to rituals, community events and social practices. In the end, however, it is a predictable, natural event that touches us all, regardless of our cultural, racial or religious background.
It seems we’re also united this time of year by a need to stop, rest, reflect and be with those who are closest to us. As the days grow shorter, and as the solstice provides indisputable evidence of our fragility in the universe, it seems that natural biorhythms urge us to slow down, cleave to what we perceive to be unshakably reliable, and restore our spiritual energy for challenges ahead.
It’s in that spirit that I wish our faculty and students a restful, safe and restorative break from the routine of busy lives, and very best wishes, as we will again come together to engage the year ahead.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Medical Students Walk in the Shoes of Kingstonians Living with Less
At this holiday time, when we focus on gift-giving, and celebrations, it is also good to reflect on those for whom gifts and celebrations are almost impossible. A few short weeks ago, Queen’s medical students participated in the Poverty Challenge which allowed them to experience living with less.
The following article was written by Dr. Jenn Carpenter and Dr. Melanie Walker who brought the Poverty Challenge to Queen’s School of Medicine.
On December 2nd2014, the first year medical students participated in a Poverty Challenge, organized by Judi Wyatt and Craig. The Poverty Challenge provided them with the opportunity to experience first-hand what some of their future patients live through on a daily basis. As part of their Population and Global Health Course, the students spent the afternoon playing the role of Kingston residents living with less and trying to solve a multitude of daily issues including access to transportation, housing, food, employment and medical care.
Throughout the fall term, the students have been learning about the Social Determinants of Health, their role as Advocate, social accountability and the fact that health is a human right in the Population and Global Health Course. The course stresses the fact that Global Health is local and that there are under-served populations in their own community as well as overseas. Students have learned about the fact that living with less increases one’s chances of ill-health and can also hinder an individual’s chances of success in many of the other social determinants of health such as education, early childhood development and positive social support networks. The Poverty Challenge was an opportunity for experiential learning of these concepts and was a way to put the knowledge that they have gained through their readings and in-class discussions into practice.
Prior to the event, each student was given information about the life and struggles of a person that they were going to role-play. They knew some of that person’s life history, why the person found themselves in the cycle of poverty and what specific obstacles the person was facing at the time. For example, one woman, who had a child at 16 and had no family support, had her child taken away by the Children’s Aid Society because her housing situation was deemed unacceptable. This, in turn, led Ontario Works to reduce her income because she was no longer supporting a child. The students assigned to this woman’s profile were tasked with visiting the appropriate social services agencies (stations located throughout the School of Medicine building and operated by community volunteers) to find employment and affordable housing while undergoing discussions with the Children’s Aid Society to get her child back.
Other students role-played the life of a women who was obese and living in an abusive relationship and was unable to find a family doctor who was willing to accept her as a patient. In addition, due to an undiagnosed learning disability, she was illiterate. The students were tasked to apply to Ontario Works for financial support (remembering the woman’s inability to read and complete necessary forms) and to go to a Temp Agency to apply for work. In addition, the students profiling this Kingston resident had to go to Legal Aid for help to leave her abusive relationship.
Over 20 local agencies were represented in stations throughout the medical building. At each of these agencies, the students encountered roadblocks similar to what the Kingston residents, of their profiles had encountered during difficult times. However, they also found out about the wonderful things that each of these agencies were able to do for them and were able to revel in the feeling of success, if and when they actually found the correct path.
Not only did the students learn important lessons about the barriers to health that people living with less face, but they also learned about community agencies that exist to help lift people out of the cycle of poverty. The feedback from the students was overwhelmingly positive. 96% percent of the students felt that the experience taught them about the challenges faced by people living in poverty and, despite the fact that the event was timetabled for the week prior to exams, 93% percent of them said that they were very glad that they took part.
A sample of the narrative feedback received from the students follows.
- “In general, the whole event was surprising in terms of the impact I noticed and what I heard from my classmates”.
- “I thought this was a terrific event. The experiential aspect really drove home just how many challenges (and of what magnitude) those “living with less” really face on a day-to-day basis […] Sometimes it is easy to forget that poverty is a problem that affects Canadians, not just those living “elsewhere,” and that many of our perceptions of and assumptions about poverty are inaccurate and based on the false assumption that “it couldn’t happen to us,” that poverty is something that one “allows” to happen rather than something that can happen to us in spite of every best intention and effort. I leave today remembering that I am very, very lucky. Thank you for reminding me of that.”
- “I came into the session feeling quite stressed about upcoming exams, and ambivalent as to the potential benefit of taking part in the Poverty Challenge. After […] experiencing (very briefly) some of the frustration involved with truly living in poverty, I’m very glad to have had the opportunity to participate. I have learned more about the holistic nature of suffering in poverty and also about the complex issues that give rise to difficult financial situations. This is an extremely well done event and I will take these lessons with me into the next few years of medical school and beyond. Thank you.”
Doctors are considered to be one of the most important advocates for their patients’ health, but this is a very difficult task without understanding the greater context (physical, emotional and environmental) in which their patients live. Our hope is that by providing these doctors-in-training with a more first-hand experience of some of the hardships that many in the community face and their implications on health we will encourage more open dialogue between doctors and patients and consideration of patient context when planning treatment.
Photos by Dr. Melanie Walker
Why, What and How We Teach at Queen’s Medicine.v3
For a teenage boy growing up in a small town, the local auto mechanic can become a best friend and key to social success. I had great admiration for one in particular who would let me watch and explain what he was doing as he went about trying to resuscitate whatever antiquated pile of spare parts I was currently passing off as my “drive”. He always seemed to be able to find a way to repair whatever part was ailing, or adapt yet another spare part to replace whatever previously adapted spare part was no longer operational. But sometimes, even he would throw in the proverbial towel. “There are times”, he would say, wiping grease from his hands, “when you just need to jack up the horn and drive under a new car”.
Many times, when grappling with really difficult and highly complex problems, we are tempted to just “blow it up and start all over again”. The concept of going back to first principles and taking a new and fresh approach that sets aside all of the partial “patch work” fixes and “spare parts” that have been put in place over the years can be hugely tempting, particularly when it’s obvious that those noble and well-intentioned attempts are now resulting in a system that is unnecessarily complex and no longer addresses the initial intent.
But we don’t often get those opportunities, particularly when dealing with established and multifaceted systems like, for example, medical schools. Former United States President Calvin Coolidge is credited with remarking that “changing a college curriculum is like moving a graveyard – you never know how many friends the dead have until you try to move them.” We tend to resist change and cling to the familiar, particularly when those changes may be seen as threatening or offensive to folks who have developed or embraced them with every good intention.
All that notwithstanding, a rather courageous (and perhaps naïve) group set out to do just that at our medical school 7 years ago. There were multiple motivations. Many faculty were expressing frustration and a sense that we could do much better. Students were quite vocal in their view that the curriculum seemed out of keeping with their needs. The catalyst was provided by a recently received accreditation review that made it abundantly clear that multiple and key facets of our program required review and that no partial repair was going to address those concerns.
And so, an intrepid group was assembled and set out on what turned out to be a year long journey to “jack up the horn and drive under a new car”. The group consisted of three clinical faculty members who were established and respected medical educators and had great familiarity with our current curriculum and its history (Lindsay Davidson, Michelle Gibson, Sue Moffatt); two specialists in medical education theory and practice (Sheila Pinchin, Elaine VanMelle); a much respected clinician and teacher with longstanding interest in the development of Professionalism and the so called “non-medical expert” competencies (Ted Ashbury); a Pathologist/Immunologist who had led our basic science group in developing and delivering what was called “Phase 1” of the curriculum (Sherry Taylor); and a freshly minted and recently recruited Master of Education who was passionate about the role of generalism and the representation of Family Medicine within our curriculum and medical school (Michael Sylvester).
Despite their differences, the group gelled remarkably well. They were united by many things but, I believe, first and foremost by a shared commitment to provide the best possible educational experience for our students, summed up rather nicely in the following statement of intent:
Our graduates will have exemplary foundations in medical competencies that will prepare them for success in qualifying examinations and in post-graduate training programs and for fulfilling careers serving their patients and their communities.
A number of key decisions followed…
- We would base our curriculum on competencies as expressed by the CanMEDS framework and Family Medicine principles of practice.
- We would use the AAMC Scientific Basis of Medical Practice as a framework for our basic science teaching
- We would use the Medical Council of Canada Clinical Presentations as a basis for teaching the Medical Expert components of our curriculum
- We needed a course-based structure in order to assign competencies and clinical presentations in a logical, integrated and progressive fashion
- We would introduce more small group teaching to complement our lecture-based approach
- We would ensure students had opportunity to monitor their own learning process by introducing formative assessments into every course
- We would identify and retain aspects of our curriculum that were very successful, such as our Clinical Skills program
- We would provide more patient-centred experiences early in the curriculum in order for the students to engage their “physician” role early and to recognize the relevance of their early learning
- We would provide more opportunities for structured learning in later years by expanding our Clerkship to two years in order to develop three periods of “Core Curriculum” where the students would come back to school to learn complex issues or those that are best introduced after they’ve engaged clinical medicine.
What emerged was dubbed the “Foundations Curriculum” which had to be introduced over four years in order to ensure every class enrolled during those years received a full, albeit somewhat different, curricular experience.
The description of that new curriculum was articulated in a document entitled “Curricular Goals and Competency-Based Objectives” that was widely discussed, passed by our Curriculum Committee and endorsed by all faculty at School of Medicine Council. Because the undergraduate office happened to have a large supply of red printing paper that was used to produce a cover, the document became known as the “Red Book”.
That document has now been revised twice, based on experience with its implementation and considerable feedback from students, teaching faculty and curricular leaders. That third version, approved recently by our Curriculum Committee, has been packaged very attractively by Sheila Pinchin and her colleagues, and is being released this week. It will be made widely available in both electronic and print formats, and should serve as an articulation of the “why, how and what” we teach, and unifying focus for all the following:
- Student Learning – this document outlines what we expect our students to know, to do and to be, by the time they graduate
- Curricular Design – our course structure, sequencing and content will all be guided by this document. Each course will be assigned some subset of the Program Objectives and MCC presentations outlined.
- Teaching Events – each one of the 3,000 or so individual teaching sessions we provide over the four year curriculum will be structured with the goal of relating to one or more of the Curricular Objectives.
- Assessments – a comprehensive “blueprinting” process developed and monitored by our Student Assessment Committee will ensure that all summative assessments relate to a subset of the objectives assigned to the course or competency to which they relate.
In summary, the “Red Book” provides a basis to ensure that the key educational triad is maintained, interrelating the three pillars of any educational program – Objectives, Teaching and Assessment. It also serves to keep all of those engaged in our educational enterprise “on the same page”.
I’m very grateful to all of our educators, students, faculty and administrative staff whose dedication and commitment make our curriculum, and our school, so special – spare parts and all.
Enjoy these early and lasting gifts from the Bracken Health Sciences Library
By Suzanne Maranda, Head, Bracken Health Sciences Library
When I meet faculty in person, especially if I’ve not seen them in a while, or if they are new to Queen’s, they often embarrassedly admit that they never come to the library. Over the years, I’ve refined my answer: ”Oh, but you do; you probably just don’t know it. Most links to full-text articles would not work if the Library had not done the behind-the-scenes work.” Medical students are also quite amazed to find out, during their first session of medical school, that a single annual journal subscription can cost more than their tuition! The Queen’s Library spends over $9 million annually on library resources, most of which are electronic. The proportion in the health sciences is among the highest, with well over 90% of the purchases allocated to online materials.
The materials purchased by this library have also changed over time. It used to be that books and journals were the only information sources for serious learning and research. In recent years, in addition to conventional books and journals, with many more online than in print, you may find, among others, point-of-care tools such as Dynamed and BMJ Best Practice, anatomy software and image banks, clinical skills videos, clinical cases, and DVDs ( the latter can be borrowed to show in class or recommended to students).
While the Canadian dollar was still strong, the Library made strategic purchases of journal backfiles, allowing perpetual online access to older journal content. Most of this electronic content is linked to PubMed and Medline and the other databases in the OVIDSP interface for seamless access to full-text.
Tip #1: After completing a database search, it is best to NOT use the “limit to full-text” option in OvidSP because that limit only retains the journals purchased via this interface provider or where it has an agreement with particular publishers. There are MANY more journals that we purchase from other vendors, but the links will display only after clicking on the “Get it at Queen’s” button.
We are also very pleased that the links to full-text have finally been implemented in PubMed! Tip #2: For the links to appear, you must link to PubMed from the Bracken Library homepage (look under Find Articles). When you click on a citation, you will see this link:
in the top right corner, sometimes in conjunction with the publisher’s link. The Queen’s links will let you know exactly what years of the journal were purchased and, if the desired article is unavailable in full-text, you will see a link to order it from our Interlibrary Loans (ILL) service.
This brings me to an important change that will go into effect early in January 2015. All health and life sciences faculty and students will be able to order interlibrary loans using RACER. This service allows you to place orders and keep track of them yourself, but more importantly, it is linked to a desktop delivery system. Requested articles will be delivered as a link embedded in an email message. Remember that the Library no longer charges for interlibrary loan requests. More information will be sent to all health sciences faculty in December.
Course Reserve: Another service has changed this fall: there are now other options to place items on Course Reserve. Faculty have always been able to request that books or print journal articles be placed on reserve for students to sign out. These items are to be highly used by the entire class, and the reserve function allows for very short loans, usually 3 hours, which ensures that the entire class can have access within a reasonable amount of time. This is still the only way to handle a complete print book, but what about a chapter? Or an electronic article? Many faculty now put links to course readings in MedTech Central, and maybe we can help:
Tip #3: Bracken Library staff can scan a book chapter or a journal article and send faculty a pdf file for upload to MEdTech Central. This also applies to existing online materials: a persistent link can be created, which insures that you are using a reliable link over time and that the item is accessible from off campus. Please send requests to firstname.lastname@example.org. Now is the time to plan for the Winter Term!
On behalf of the entire Bracken Library staff, please accept my best wishes for the holiday season and for a healthy and productive 2015.
Curriculum Committee Meeting Highlights – October 23 and November 27, 2014
Faculty and staff interested in attending Curriculum Committee meetings should contact the Committee Secretary, Candace Miller, at email@example.com for information relating to agenda items and meeting schedules.
Highlights from October 23, 2014:
The Curriculum Committee has now approved the following:
- Visiting Medical Electives Policy (updated)
- Observership Policy and Procedures (updated)
Highlights from November 27, 2014:
The Curriculum Committee has now approved all of the following:
- Terms of Reference:
- Course and Faculty Review Committee (updated)
- Curricular Hours Policy (updated)
- Examinations Regulations Policy SA-02 (updated)
- Clinical and Educational Activity in Clerkship Policy (updated)
All Undergraduate Medical Education policies and terms of reference are available on the UGME website: http://meds.queensu.ca/undergraduate.
Next Meeting: December 18, 2014
Medical Student Debt:
Is it a problem, or just a shrewd investment?
By the end of his or her medical education, the average Canadian graduate will owe $71,721. That amount, which has increased by about 7.3% over the past 5 years, may seem either huge or trivial depending on your perspective and stage of life. Interpretation might be enhanced with a few more details:
- 17.5% manage to get through medical school with no debt at all, a figure that has not changed over the past 5 years.
- on the other extreme, 6.2% report debts of over $200,000, which has increased from 4.1% in 2010
- 28.3% report already having debt before even entering medical school (26.4% in 2010), with an average premedical indebtedness of $7,465 or, perhaps more telling, an average of $27,094 for those who report any debt (comparing to $6,506 and $25,968 respectively for 2010).
- 32.5% report having accumulated “non-educational debt” during medical school (eg. credit cards, car loans, mortages) averaging $23,976 (comparing with $31,455 in 2010)
- 28% feel that the amount of financial assistance available to them fails to meet their needs (compared to 31.5% in 2010)
- 3.7% report “no need for financial assistance” (unchanged over the past 5 years)
All this comes from the Canadian Medical School Graduation Survey, which is conducted as part of the Academy of American Medical Colleges Graduation survey and was completed (voluntarily) by 2,048 graduating students in 2014 including (I’m pleased to report) 99% of our graduating class at Queen’s.
At the same time, tuition rates appear to be on the rise (http://studymagazine.com/2011/11/01/tuition-canadas-medical-schools-rises/), currently averaging about $11,000 annually, but with considerable variability between schools, ranging from as low as about $4,000 to highs of over $25,000, according to the Canadian Medical Education Statistics published by the Association of Faculties of Medicine of Canada (http://www.afmc.ca/pdf/CMES2014-Complete-Optimized.pdf).
So, what does all this mean? Is this a problem that we and other medical schools need to engage, or are we observing what is, from a strictly financial perspective, an investment by shrewd and well- informed young people in an education that will lead to a secure, well-paying future in which they should be able to quickly dissipate even the higher levels of indebtedness?
On the “what’s the fuss” side of this argument are those who point out that medical students, once enrolled, have easy access to large loans from banks and other institutions who are confident in their success and financial prospects. They would note that almost all medical students graduate to lucrative careers (unlike most other university graduates), and that even a resident physician’s income, sensibly managed, provides the means after graduation to pay down those loans. They would further point out that there is very little post-graduation default on debts. Finally, they might make the point that these students are, in fact, adults who make conscious and highly informed career and financial decisions, and that medical schools are either their parents nor socially responsible for those decisions.
Those on the “we have a problem” side of this issue might make the following points:
- Although manageable after medical school and a minor issue in retrospect, the perception of increasing debt during medical school is a major stressor for students during an admittedly demanding period of their training, and may therefore distract from their education
- The high debt load may influence career decisions, prompting students to consider specialties with shorter duration of training and greater perceived long-term economic benefits.
- High debt load may discourage students from taking up research, educational or other academic training opportunities, either in parallel with or after their core training.
- The high costs and accumulated debt may discourage many young people from socioeconomically challenged backgrounds from even considering careers in medicine, thus establishing a further barrier to the social diversity that all medical schools and the medical education community are endeavouring to establish. To quote the AFMC’s Future of Medical Education In Canada: A Collective Vision for Medical Education in Canada:
“Achieving this diversity means attracting an applicant base that is more representative of the Canadian population. This will involve, for example, addressing perceived and real barriers to medical education, such as the high debt loads of medical graduates.”
The last point is particularly vexing. It’s easy to imagine that, for a family of limited financial means and with incomplete knowledge of the financial realities, the prospect of over $20,000 in annual tuition and possibly hundreds of thousands in accumulated debt may be sufficient to quash any dreams of medical education very early in life. (see previous blog article http://meds.queensu.ca/blog/undergraduate/?p=1165&preview=true&preview_id=1165&preview_nonce=e904b6e40f&post_format=standard).
In addition, there are considerable financial hurdles a student must face to simply apply to medical school, including three to four years of pre-medical undergraduate medical education, MCAT examinations (including preparation and travel) and quite likely a sense that income-generating jobs should be sacrificed in order to pursue studies or activities deemed more “attractive” to medical school admissions officers. Although considerable financial assistance and loans are available to students once accepted to medical school, there is no similar level of assistance to those in the application process where it would arguably be of greater benefit.
At Queen’s, we are concerned about the rising profile of student indebtedness and it’s impact on both current and prospective students. To further examine this issue, we have established an Advisory Panel on Medical Student Debt, chaired by Dr. Greg Davies and supported by Brian Rutz, UG Financial Officer. The panel is populated by several current students from all years, recent graduates in residency training, not-so-recent graduates now in the early years of independent practice, and several members of faculty and the university community with interest in this issue. That group has already begun its work by undertaking a review of the Canadian medical school environment through the Graduation survey, and current literature. It is focusing on several topics:
- The sources of debt
- The impact of debt on individual students
- Counseling and information sources available to students as they engage financial planning
- Financial aid availability and access
- How support might be provided to young people considering careers in Medicine
Their findings and recommendations, once available, will be brought forward for wide discussion and implementation. I’m sure Greg and his committee would appreciate hearing from readers about any and all of these issues. I know I would.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education