“Visions of sugar plums” and that which endures

Clement Clarke Moore (1779–1863) accomplished much during his lifetime.clement

He was a Professor of Oriental and Greek Literature at the General Theological Seminary in New York City.
His philanthropy led to the development of the section of New York City known at Chelsea.
For many years, he served as a Board member for the New York Institution for the Blind.He produced the two-volume A Compendious Lexicon of the Hebrew Language (1809).
He translated from the French of A Complete Treatise on Merinos and Other Sheep (1811).
He authored a number of treatises and political pamphlets, the most well known being an 1804 attack on then president Thomas Jefferson, somewhat ponderously entitled “Observations Upon Certain passages on Mr. Jefferson’s Notes on Virginia Which Appear to Have a Tendency to Subvert Religion and Establish a False Philosophy”.
He wrote the historical biography George Castriot, Surnamed Scanderbeg, King of Albania (1850), which was apparently highly acclaimed at the time.
Throughout his life he also wrote poetry, which was published in the Portfolio and other periodicals of the day.

blog75-1Despite all this scholarship and civic leadership, the work for which Mr. Moore had the greatest societal impact, is most famously acclaimed, and remembered to this day, is a simple poem he wrote on Christmas Eve 1822 for the entertainment of his own children entitled “A Visit from Saint Nicholas”. In it, he describes Saint Nicholas as “a right jolly old elf”, who arrives on Christmas Eve in an airborne sleigh propelled by eight fancifully-named flying reindeer and enters homes leaving toys for the children. We, of course, have come to know that poem as “The Night Before Christmas”, and recognize that it gave rise to a rather prodigious, endearing and enduring cultural (and commercial) mythology.

blog75-2He never intended for the poem to be published. In fact, it’s said that he was embarrassed that his much more scholarly works were overshadowed by what he considered a trivial work written to calm his overly excited children on Christmas Eve. Over the years, there has been controversy regarding its true authorship, since he didn’t acknowledge it until years after its initial publication. Nonetheless, it has not only survived the passage of time, but has flourished and essentially shaped the Christmas experience of generations of children, not to mention many other literary works, plays, songs and motion pictures.

The story of Mr. Moore and his most enduring work provide interesting lessons and insights. It speaks to the fundamental human appetite for whimsy, willing suspension of reality, and our craving for optimism – the belief in human generosity, and that good things will come to us ‘just because’. Let’s acknowledge that the concept of a kindly, giving, fatherly Santa Claus hasn’t endured simply as a childhood fantasy. After all, children haven’t been purchasing or reading “The Night Before Christmas” themselves over the years. It has endured because those children grow into parents who retain some element or aspiration for that spirit, and wish to pass it along as a gift to their children.

The other lesson from Mr. Moore’s life story, of course, is that we don’t get to choose our legacy. History is replete with examples of people who are remembered not for what they intended or for what they believed they were building through their lives, but for their own personal attributes and how those attributes affected those around them and those who followed. The passage of time provides a harsh and impartial judgment of the worth of what we do. Empires and civilizations rise and crumble. The names and stories of those who led them fade into obscurity “as dry leaves before the wild hurricane fly”, but the human spirit, with all its foibles and idiosyncrasies endures and, with it, the memory of those who express it in various forms. Admiration for those creative, artistic people endures and grows over the years.

I close my last blog of 2015 with a reproduction of the initial, anonymous publication of Mr. Moore’s most enduring work as it appeared originally in the Troy Sentinel in 1823. A little hard to read, but I suspect you can fill in the words.


Happy Christmas, indeed.

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


Thanks to Lynel Jackson for her always valuable assistance with the illustrations.


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MD Program Executive Committee Meeting Highlights – December 16, 2015

Faculty and staff interested in attending MD PEC meetings, should contact the Committee Secretary (Faye Orser, (orserf@KGH.KARI.NET)) for information relating to agenda items and meeting schedules.

School of Medicine Building – Flood Repairs

Dr. Sanfilippo was happy to announce that the repairs to the building are wrapping up and classes will resume in the lower lecture theatre as of January 4.  He would like to extend his appreciation to everyone for their patience and efforts to make this term successful despite the space challenges.  Thanks also to Kevin McKegney for his continuing efforts to ensure repairs progressed as expeditiously as possible.


Dr. MacDonald reported that the Admissions Committee are looking at several areas which may impact the admission process in future years.  MD PEC was asked for input on topics such as the School’s diversity statement and policy, pipeline programs and whether the School defines itself has having a National or Regional perspective. These issues will be considered in upcoming meetings of MD PEC.

Transfer Student Policy

The Committee approved a newly developed policy relating to MD students from other education institutions requesting transfer into the Queen’s MD program.  This new policy formalizes existing practices and is not intended to alter or change the School’s current approach.

Audio and/or Video Recording of learning events in the UGME Policy

The Committee approved a newly developed policy allowing video recording of UGME lectures.   A pilot project is being established to test the effectiveness and viability of the capturing of lectures for student viewing.

All Undergraduate Medical Education policies and terms of reference are available on the UGME website:  http://meds.queensu.ca/undergraduate


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Socrates, “pimping” and teaching in medical education

Recently, one of the words in the title of an article in Academic Medicine really caught my eye: “Socrates Was Not a Pimp:  Changing the Paradigm of Questioning” by Dr. Amanda Kost and Dr. Frederick M. Chen. (Kost & Chen, 2015)

Of course, the word that caught my eye was “Socrates,” he of sitting with students under an olive tree fame

20120223-Socrates Greuter

and, of course,  from Bill and Ted’s Excellent Adventure. socrates with bill and ted

Much of the scant information we have about Socrates is from his students, Plato and Xenophan.  Plato portrayed Socrates as an excellent teacher and questioner, in the Dialogues, where a series of questions is asked not only to draw out individual answers, but also to encourage fundamental insight into the issue at hand.

Can it be, Ischomachus, that asking questions is teaching? I am just beginning to see what is behind all your questions. You lead me on by means of things I know, point to things that resemble them, and persuade me that I know things that I thought I had no knowledge of.

–       Socrates (Quoted in Xenophon’s “Economics”) Portrait Herm of

Of course, I can’t deny that another word caught my eye in the title:  It’s not always that you see the word “pimp” in a medical education journal.

However, it’s a common term in medical education, since 1989 at least, where Brancati used it to refer to a questioning method that is supposedly Socratic but is defined as “whenever an attending poses a series of very difficult questions to an intern or a student.” (Brancanti, 1989) He suggests questions “should come in rapid succession and be essentially unanswerable.”  There are other definitions, and the “not a pimp” authors Drs. Kost and Chen, write that in these definitions the purpose of the practice is to reinforce the power hierarchy of the team and, more specifically, the attending physician’s place at the top. (Kost and Chen, p. 21)

In a 2005 study, by Wear et al. fourth year medical students were questioned about the practice of this form of questioning:

Students divided pimping into “good” and “malignant” categories. “Good pimping” actions included questioning that advanced or enhanced the learning process and also encouraged students to be proactive about their learning…“Malignant pimping” frequently employed techniques designed to humiliate the learner. All students in this study identified humiliation as an outcome of any type of pimping—even good pimping had a component of shame because of the public embarrassment of not knowing the answer.  (Wear, et al, 2005 cited in Kost & Chen)

I’d like to discuss “pimping” both from a syntactical and a pedagogical perspective.

I was trained as a language educator to acknowledge that language has a very pronounced impact on constructs in our thinking.  I have to admit that I don’t get the use of the term.  The other definition of pimp:  a person, especially a man, who solicits customers for a prostitute or a brothel, usually in return for a share of the earnings; pander; procurer (Online Dictionary and Merriam-Webster Dictionary) seems to have very little to do with questioning, whether benign, or malignant.

“Pimping” then… you know, that’s the last time I’m going to use the word! I dislike the relationship it implies that could so easily settle into the hindbrains of all us who have been using it.   With your permission, I’m going to try “hounding” instead.  Drs. Kost and Chen agree with me: “This word may evoke a negative affective response, and we would also argue that the use of such a derogatory term to describe an experience in medical education is unprofessional.”

Because, you see, questioning is one thing, and is an excellent and powerful educational tool.  However, when does questioning move into “hounding”? It happens when the questioner is pursuing a different goal than a pedagogical one:  perhaps humiliation(“She needs to know this stuff”), or going way beyond the knowledge of the level of the learner (“Shouldn’t clerks know this, or is it residents? Fellows?”) or venting frustration and anger (“You guys think you’re so smart? Well, let’s see…).  They include the well-known “Read my mind” type of question, and the question that is so obscure that very few know the answer (except perhaps the questioner?).

In the Wear study, students felt questioning  “was useful to “promote learning, logical thinking, defending one’s decisions, quick recall, self-assessment, and communicating well with one’s peers.”  They didn’t like the hounding part of it, and wanted to use volunteering answers as an alternate to centering someone out and hounding them. (I know, I know…this can be an important part of questioning…I hear you and I’ll come back to this.)

So, let’s get back to Socrates.  The Socratic questioning method is used often today, tho’ it appears it can be misunderstood.  In a recent vehement and lively DR-ED listserve discussion, the Socratic method was linked heavily with “hounding” by one participant.

Socrates used the dialectic method of teaching, whereby he assumed the role of someone who knew nothing about a topic, and drew the students’ ideas out, through a series of questions, each one probing more in depth or looking at different options. (Fun fact:  Did you know that the word “education” comes from the Latin ex ducere (to lead or draw out?)

The scientific method, which begins with a hypothesis and then proves or disproves the hypothesis is widely credited with having its roots in the Socratic method. just saying

Since Socrates was mainly concerned with students uncovering their own beliefs, and the validity of those beliefs, the correction of misconceptions and reliable knowledge construction all around large concepts such as truth and justice, modern teachers have created a sort of system for modern Socratic questioning of all types of learning.  Here are some of the characteristics:

1.    Students are questioned in a group, and in modern times, others in the group can collaborate with each other to find answers.  But not always…Socrates challenged his listeners and students.  And he picked them out, as well as had them volunteer.  But learners could help each other.  You’ll see in this sculpture, Socrates teaching in the Agora, by Henry Bates,  below how avidly everyone listens to each other.listening

2.    Socrates believed questioning would motivate learners and help them to the joy of learning. Thus, questioners should create a safe and comfortable context for questioning, where wrong answers are simply a signpost to heading down another path of learning.  In other words, they wouldn’t mind being centred out because they were enjoying learning.

3.  Use of by “why”, “what if” “how”, “then, if…” or open-ended questions vs. closed ended questions such as “What is this object?” “What is 1+1?” (Perhaps we can start with close-ended questions especially for novice learners, but they shouldn’t be the end goal of the questions.)

socrates and exams

3.  Socratic questions must be: 1) Interesting, 2) Incremental, 3) Logical (moving from the student’s prior knowledge towards a goal), and 4) Designed to illuminate particular points.

4.  Questions should be well-planned with a goal of benefiting the student at his/her learning level in mind.  Sometimes you have to start factually, but there should be progression toward critical thinking.

Let’s summarize, and then I’m going to prepare for you to write in to tell me what you think about “hounding” and questioning:

1.    Let’s not use that word again…it’s really ugly semantically.

2.    Hounding is not questioning.  Hounding is hounding and it’s not supported pedagogically. Questioning is an excellent way to teach.  It doesn’t have to be sweet, nor does it have to be easy.  It has to be respectful and with the appropriate underlying purposes.

3.    If we’re going to claim that “hounding” is Socratic, or even our questioning strategies are Socratic, let’s start using Socrates’ methods more.  Let’s aim for critical thinking questions, one of Socrates’ key purposes in questioning.i cannot make

4.    Let’s focus on our learners and tailor questions to their learning level.

5.    Let’s create a climate where questioning is accepted and even welcomed.  Let’s give our learners appropriate language to acknowledge they haven’t prepared, or are at the limits of their abilities thus far and need assistance.

In my next column (look for it in January 2016), I’ll provide more suggestions—based on Socratic principles—for keeping Questioning productive.

So, what do you think?  Are you a Socratic questioner?  Do you think hounding has a purpose?  Are there aspects of your teaching and questioning that can be enhanced through Socrates?

Looking forward to hearing from you about this.

And it’s not a smooth segue, but while I’m here with you, I’d like to take this opportunity to wish you all the best of the season!

seasons greetings

And here’s to great teaching in 2016!




Brancati FL. (1989). The art of pimping. JAMA. 262:89–90.

Dictionary.com http://dictionary.reference.com/browse/pimp and Merriam-Webster Dictionary http://www.merriam-webster.com/dictionary/pimp

Kost, A.& Chen, F.E. (2015). Socrates was not a pimp:  Changing the paradigm of questioning in medical education. Academic Medicine, 90: 1.

Wear D, Kokinova M, Keck-McNulty C, Aultman J. (2005). Pimping: perspectives of 4th year medical students. Teach Learn Med. 17:184–191.




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Justin Trudeau, “knowing when you might not know” and metacognition in medical education


I will admit to being one of those people who went into the last election believing Justin Trudeau was “just not ready”. Too young. Too cocky. Too good looking. Just too perfect. Too dissimilar, I believed, from his famous father who I greatly admired and supported in the past. In fact, over forty years ago, I was quite an ardent supported of Pierre Trudeau. My brother and I were Young Liberals who campaigned actively for his election, and even had the opportunity to meet him briefly at a party event. He was young, intellectual, worldly, unabashedly unconventional, and professed a fresh vision of an open and inclusive “Just Society” that was, frankly, inspirational to idealistic (and probably naive) young people who were eager for change after the long line of staid and decidedly uninspiring conservative leaders who preceded him.

I was explaining all this to one of my sons a couple of weeks before the election when he asked, rather innocently, how was Justin so different from his father? What’s different now than then? Well, I began to explain wisely (and rather defensively), the world’s a vastly different place, much has changed…blah, blah, blah. No doubt true, but as I considered all this further I came to realize that what’s really changed, what really underlies my doubts about young Justin, is me. My own attitudes and perspectives have changed rather profoundly, altering both my comfort with status quo and willingness to embrace uncertainty. All this also brought to mind a piece of advice I came across in a leadership article recently:

“You need to know what you know, what you don’t know, and when you might not know”

All this speaks to the concept of Metacognition. This term, easily dismissed by the righteously self-assured as edu-babble, refers to “cognition beyond cognition” or, more simply put, “thinking about thinking”. The essential concept is that helping students develop self-awareness about their own learning strengths and weaknesses will make them better learners, both now and through their careers. Brings to mind the adage “give a man a fish, you feed him today – teach him to fish, he feeds himself”.

Contemporary interest in metacognition is credited to developmental psychologist John Flavell who published a number of articles in the 1970s which have triggered considerable educational theory. The concept and practice, however, is ancient and is perhaps best exemplified by Socrates who famously challenged his students with probing questions, forcing them to examine and question their own thinking process rather than simply their ability to relate factual information. Many believe that the single quality that differentiates the accomplished and comfortable learner from those who struggle, is the ability to understand how they learn and their ability to take charge of that process.

This is highly relevant to the teaching and learning of Medicine. Effective Physician teachers intuitively and instinctively foster metacognition whenever they challenge their students to explain their thinking or “approach” rather than simply produce a fact or single response to a problem. The emphasis on reflection and portfolio development in medical school are attempts to foster this awareness in our novice learners. Accomplished, highly regarded diagnosticians and scientists are not simply sources of accumulated knowledge. They are expert problem solvers who are able to focus their thinking and creativity on fresh challenges. In fact, they thrive on such challenges and are bored by repetitive application of “conventional” wisdom.

In addition to recognizing and refining our own learning processes, metacognition forces us to confront the fact that we may harbour unintentional cognitive bias. Even a casual search of the term uncovers numerous examples of such latent biases that sound disturbingly relevant to medical decision-making, and probably affected my election decision dilemma. Consider the following:

Anchoring is the tendency to rely too heavily on one trait or piece of information when making decisions. Consider our reliance on demographics, specific risk factors, clinical findings or diagnostic test results that we favour or are more adept at interpreting.

Availability cascade refers to the tendency to rely on events more “available” in our memory, which can be influenced by how emotionally charged they may be. This seems relevant to a physicians tendency to be strongly influenced by recent, adverse outcomes.

Choice-supportive bias is the all-too-human tendency to remember one’s choices as better than they actually were. Enough said.

Confirmation bias is the tendency to search for or interpret information in a way that confirms one’s preconceptions. In medical terms, favouring data that supports our hypothesis and discounting information that doesn’t.

Conservatism is resisting new evidence. The Semmelweis Reflex has come to be associated with rejection of new ideas simply because they’re new. It’s named for Ignaz Simmelweis, an Austrian physician who, in 1846, postulated and observed that maternal and infant mortality was much higher on wards where the physicians moved between autopsies and wards without washing their hands. Semmelweis met with great resistance from his colleagues. In doing so, those colleagues were demonstrating the Status quo bias, which is the tendency to want things to stay the same, to the extent that it prevents appreciation of new ideas or approaches.

Framing effect refers to our tendency to draw different conclusions from the same information, depending on how that information is presented. Any of us who have learned how to deliver critical feedback in conjunction with positive commentary knows what this is about. A related term is selective perception, the tendency for expectations to influence perception – we see what we wish to see.

Negativity effect is the tendency to unevenly evaluate the behaviour of a person one dislikes. This leads us to attribute their positive behaviours to the environment and their negative behaviours to the person’s inherent nature. Our political leaders, most recently Mr. Harper, are undoubtedly victims of this phenomenon.

Optimism bias is the tendency to be overly optimistic with respect to outcomes that we see as favourable or intrinsically pleasing. No doubt Mr. Trudeau benefited from this during the recent election. In the medical context, this might influence how we express interview questions, hoping to develop a picture of favourable outcome to therapies we’ve provided.

Reactance is the urge to do the opposite of what someone wants you to do because you perceive constraint to your freedom of choice, or sense of control. This speaks to less noble aspects of our nature, and is linked to reactive devaluation in which we devalue proposals or suggestions only because they originate from someone we do not value or view as an adversary.

All these concepts relate to limitations fundamental to our human nature and are relevant whether we’re doing the weekly grocery shopping, voting in elections, or making medical decisions. It also seems clear that nothing about the concept of Metacognition is new, in either Medicine or in everyday human affairs. Recognizing it as a valid learning process, and acknowledging the various ways in which our own engagement of new ideas and decision making can be unintentionally influenced is, I believe, of considerable value.

Trudeau-blog2By the way, I’m still not sure about young Justin, but I voted Liberal.


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

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WF Connell Award – New Terms of Reference Approved at MD PEC

Walter Ford Connell was by all accounts a highly regarded educator and mentor here at Queen’s.  Among many accomplishments he’s remembered for his critical role in the achievement of admitting women to the program and inspirational guidance to many graduating students.

For many years an award in his name has been presented to a faculty member at convocation.  The award has been for ‘greatest contribution to students education’ and is the only teaching award presented.  It is managed by the Aesculapian Society who determine the winner through a nomination and voting process.

This year the Society proposed expanding the award to faculty who are voted as best in three teaching domains:

  • Excellence in Clinical Teaching
  • Excellence in Lectureship
  • Excellence in Mentorship

After input from senior faculty the revised terms were approved by MD-PEC.

It will be great to see this award presented to deserving faculty in these three vital areas at the convocation reception this spring.

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