Month: April 2016
Jordan Spieth’s painful pursuit of perfection, green jackets, and learning from failure.
The Masters Tournament is almost too perfect. The golf course itself is pristine and picturesque – every vista a postcard. The golfers are skilled, the spectators robotically well behaved, the commentators obsequious in their adulation of the players, the course, the “tradition”. Even the caddies are required to dress in the same white overalls, seemingly to blend in and not distract from the scenery and spectacle. The winner is presented with a jacket, the colour of which one would select for no other purpose. The result of all this is a bizarre collision of the sporting world with the Stepford Wives, all set in Fantasyland.
Despite all this artifice and contrivance, frail humanity emerges from time to time, and it certainly did earlier this month at this year’s tournament.
One year ago, Jordan Spieth, a 21 year old previously unheralded professional golfer, won the tournament in rather spectacular fashion. In doing so, he displayed a degree of skill and poise that one normally associates with much more “mature” professionals. He immediately vaulted to the top of the golfing world, that world rather desperately in search of a new hero following the precipitous demise of one Mr. Woods (another story). Mr. Spieth took up the mantle with aplomb, continuing to win several tournaments over the following year, always with a reserved dignity and deference for “the game”, winning the admiration of true aficionados.
All this came crashing down about half way through the final round of this year’s tournament. At that point Mr. Spieth had been leading since the start and was a full five strokes ahead of the field. Commentators had begun the coronation, speaking in hushed, admiring tones of his youth and speculating on how many records he would break during the career before him. The fans were poised for a repeat winner. All was right in the golfing world.
And then, the improbable, the unexpected, the inexplicable…happened. Mr. Spieth began golfing like a Sunday duffer. Balls were struck in errant directions, poor swings, bad decisions, two balls in the water. In less than an hour, the five stroke lead turned into a two stroke deficit. He looked, for the first time in his young career, visibly shaken, even bewildered. The perfection he’d achieved and come to expect based on all his prior experience seemed to abandon him. He tried valiantly to recover, but to no avail. He ended tied for second place, losing to a previously little known golfer from Britain named Danny Willet, whose manner and demeanour upon winning seemed more akin to an English Premier League soccer game, a point not lost on either the commentators nor rather staid tournament officials.
To make matters worse for Mr. Spieth, he was required to engage in the traditional ceremony that calls for the previous champion to present the green jacket to the new winner. His expression at that time really said it all.
So what will become of Mr. Spieth? Retired golfers and previous champions, when asked to comment, spoke catastrophically of the depth of trauma speculating that “he may never recover psychologically”.
From time to time, sporting events present revealing and poignant insights into the human condition. Those insights are not provided by times of great accomplishment and perfect application of practiced skills, but rather by times like these, when all of us can identify with the person and derive insights for ourselves. Golf provides a particularly apt metaphor because the object of the game is perfection, as defined rather clearly for every hole played. We all recognize that perfection is an unobtainable aspiration, but the trap for the very proficient, like Mr. Spieth, is that they live tantalizingly close to that goal and have made it their life’s work, so that times of failure are magnified in importance and, of course, very public.
The relevance to students and practitioners of medicine is obvious. We strive for perfection and mistakes, although rare, can be both consequential and visible.
Mr. Spieth, the golfer, has come second in a tournament that was his to win, but remains one of the most proficient practitioners of his craft in the world, and retains the potential to have a long, lucrative, perhaps uniquely successful career. But the test he now faces has nothing to do with golf skill. It has everything to do with Mr. Spieth, the man, and his ability to engage the same frailties and inevitable adversities we all face in our much more mundane lives.
Folks with great potential (talent, skill, natural gifts) are relatively common in our world. Such natural aptitude that crumbles in the face of adversity is of little reliable use to anyone. And adversity, unfortunately, is inevitable for us all. It’s inevitable in the sporting world, the business world, and certainly in the study and practice of medicine.
Moreover, the ability to not only endure but to actually learn from and improve as a result of those negative experiences is a defining attribute of those few who become truly great practitioners of their chosen professions.
The term that’s become most commonly associated with this trait, is resilience, and sports clubs, businesses, the military and medical training programs, are all looking for it.
So what is resilience? Basically, it is what allows us to overcome adversity. Much is being written on the topic, but in application to Mr. Spieth’s challenge, and the challenge faced by medical folks regularly in the course of their work, it might come down to five key issues.
Commitment. Adversity tests the true depth of commitment to our chosen occupation. How much do we really wish to pursue the life we find ourselves living? For the uncommitted, adversity provides excuses and convenient exit strategies. For the truly committed, it galvanizes resolve, allows us to push through those difficult experiences, and even promotes learning from them.
Confidence. Adversity experiences challenge self-confidence. Furthermore, they provide something of an acid test as to whether the confidence that takes us to work each day is founded on a truly held, internally validated faith in our own abilities, or is an illusion buttressed by fragile external validations.
Perspective. The ability to see a single issue for what it is. One failure, no matter how dramatic and visible, should not outweigh or excessively distract from otherwise consistent success. This lesson is obviously harder for the young.
The support of people we trust. Whether friends, family or mentors, we all need people we trust to have our best interests at heart, and who possess the judgment and objectivity to help us find our way through these experiences. They are precious and indispensible.
Time. Recovery takes time. Time to renew commitment, to restore confidence, to gain perspective. The greater the trauma, the more time required. We are skilled at deferring, but ultimately cannot and should not avoid coming to grips with negative experiences at some point. “Pay me now, or pay me later”.
Having said all this, I’m not worried about Mr. Spieth. It seems, at least to the casual observer, that he has the first two attributes well in hand. His family and friends, I’m sure, will provide the perspective, and time is on his side. He is, and will continue to be, a highly successful golfer. This experience will likely make him an even greater golfer, and even more admired for having overcome it. By undergoing his adversity experience in such a public and dramatic fashion, he provides us all a gift of insight that we can apply in our imperfect lives and careers, perhaps something far beyond golf and the pursuit of green jackets.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
CCME 2016: We came, we saw, we presented!
It’s been a busy four days at the Canadian Conference on Medical Education in Montreal – five or six days for those involved in business meetings and pre-conference workshops that started on Thursday.
In addition to attending sessions, plenaries and business meetings, Queen’s contributors were lead authors, co-authors, supervisors, and collaborators with colleagues from other universities. We presented posters, led workshops, and gave oral presentations.
All told, close to 80 members of the Faculty of Health Sciences – faculty, administrative staff, and students – contributed to producing 36 workshops, oral presentations and posters. While not all of these people were in Montreal, Queen’s was well represented in the conference rooms.
We invited those participants to share information on their presentations as well as any thoughts they had about the conference itself. (Keep in mind that it’s been a jam-packed weekend and we weren’t able to track everybody down.) Here’s a sampling of what went on:
Alyssa Lip and Shannon Chun (MEDS 2017) gave an oral presentation on the progress of the Wellness Month Challenge which was developed by the Queen’s Mental Health and Wellness Committee. “This year, this challenge has expanded to 12 medical schools across Canada and reached 1085 medical students,” Alyssa noted. “In addition, we found a significant increase in resiliency in students surveyed before and after participation in the initiative.”
Laura Bosco and Jane Koylianskii (MEDS 2017) presented on the “Impact of Financial Management Module on Undergraduate Medical Students’ Financial Preparedness.”
“We created a novel web-based financial management educational module with the aim to educate medical students on the expenses of medical school, as well as the various sources of available funding, and outline the necessary steps to achieve the most financial support throughout undergraduate medical education,” Laura explained. “Our primary objective aimed to compare medical students’ financial stress prior to and following the completion of this financial management educational module. This issue is important because medical students often make residency and career decisions that are influenced by their accumulated financial debt, and we feel that the process of career selection and development should revolve around students’ interests, not financial barriers.”
Brandon Maser (MEDS 2016) presented a poster on the CFMS-FMEQ National Health and Wellbeing Survey. “The Canadian Federation of Medical Students and the Fédération médicale étudiante du Québec have worked together developing and implementing a national survey on medical student health and wellbeing at all 17 Canadian medical schools,” he said. “With approximately 40% national response, we now have a wealth of data on medical student health, and will be working with faculties and medical societies in order to elucidate risk and protective factors for medical student health, and to create recommendations for the improvement of supports and resources.”
Louisa Ho and Michelle D’Alessandro (MEDS 2017) presented on the Class of 2017’s Reads for Paeds project. “Reads for Paeds is a Queen’s medical student-led initiative that seeks to develop engaging, illustrated, and age-appropriate books for children with specific medical conditions,” Louisa explained. “Our study shows that participation in a student-developed and student-led service-learning project like Reads for Paeds can enhance students’ understanding and application of CanMEDS roles, thus benefitting their overall development as medical trainees.”
Jimin Lee (MEDS 2017) was one of several students who prepared the poster presention on Jr. Medics. “We evaluated the Jr. Medics program at Queen’s medical school as a service learning project,” she said. “We found that while engaging with the community by teaching basic first aid skills to local elementary school students, medical students developed competence in the CanMEDS roles as a communicator and professional. Our findings support the development of service learning opportunities for medical students with explicit learning values for students and quantifiable outcome in the community.”
Justin Wang (MEDS 2017) shared information on “SSTEPing into Clerkship”: A Technical Skills Elective Program for Second Year Medical Students, which was prepared with coauthors Tyson Savage, Peter (Thin) Vo, Dr. Andrea Winthrop, and Dr. Steve Mann“The Surgical Skills and Technology Elective Program is a 5-day summer elective program designed for second year medical students to teach and reinforce both basic and advanced technical skills ranging from suturing to chest tube insertion,” he said. “Anxiety as well as a lack of both knowledge and confidence in the performance of technical skills has been found to inhibit medical student involvement in real clinical settings. Our research found that anxiety was significantly decreased, confidence and knowledge were significantly increased, and objective technical skills were significantly improved immediately after program completion as well as 3-months later, demonstrating retention of these effects. These results support the use of a week-long surgical skills program prior to the start of clerkship for second year medical students.”
Alessia Gallipoli (MEDS 2017) presented her poster on an “”Investigation of the Cost of the CaRMS Process for Students”, completed with Dr Acker. “It looks at the average costs that graduating medical students can expect to pay in regards to different aspects of the residency application and interview process,” she said. “The results of this study may help students make informed decisions throughout the CaRMS process, to balance career ambitions with smart financial planning. It can also inform initiatives to support students both financially and with career planning throughout their training.”
Jason Kwok (MEDS 2017) presented on a novel method of teaching direct ophthalmoscopy to medical students in the current medical curriculum, where there is decreasing emphasis and time dedicated to ophthalmology. “Our learning method, which consists of a peer competition using an online optic nerve matching program that we created here at Queen’s University, effectively increases the self-directed practice, skill, and learning of direct ophthalmoscopy in medical students,” he said. “This learning exercise has been implemented in the first year Queen’s medical curriculum for the past two years with great success.”
Vincent Wu (MEDS 2018) noted, “The CCME serves as an avenue for us to present the accomplishments of the First Patient Program, as well as some of the unintended student learning themes. This research helps to further refine student learning within the undergraduate medical curriculum, in order to better understand healthcare delivery from the patient’s perspective.”
Adam Mosa (MEDS 2018) presented his research on using patient feedback for communication skills assessment in clerkship in a project entitled Sampling Patient Experience to Assess Communication: A Systematic Literature Review of Patient Feedback in Undergraduate Medical Education. “This project highlighted a paucity of studies on how to use patient feedback, which is an untapped source of learner-specific assessment of this fundamental CanMEDS competency,” Adam said. “CCME 2016 was a great place to meet like-minded educators. In particular, my suggestion for an “unconference” was chosen, and I spent time discussing the future of patient feedback with a diverse group of enthusiastic participants.”
Amy Acker (Pediatrics) presented a workshop with two other pediatric program directors (Moyez Ladhani and Hilary Writer from McMaster and Ottawa) to help give concrete suggestions for teaching and assessing some of the challenging non-medical expert competencies. “We came up with the idea and thought it was a session we would have liked to have attended when we started as PDs,” she explained. “We took participants through a blueprinting exercise to identify what they need to teach, resources they will need to teach and how to assess, in case-based format… hopefully everyone learned something!”
Catherine Donnelly (School of Rehabilitation Therapy) was the PI on the Compassionate Collaborative Care project, which was funded by AME “The Phoenix Project”. “The aim of the project is to support the development of compassionate care,” she said. “The output of the project was an online module intended for use by health care students, clinicians, educators and administrators. The module consists of 6 chapters that can be used independently or collectively. The modules have been pilot tested and evaluated with students and health care providers. The modules are open access and can be found here.
Karen Smith (Associate Dean, Continuing Professional Development), shared information on her team’s work: “I am here with my CPD and FD colleagues. We presented at the CPD Dean’s Business meeting on how to meet CACME accreditation standards. We will be sharing some of our scholarly work with posters and a workshop exploring aspects of what makes self-directed learning effective and what CanMEDS competencies are addressed in SDL and the impact of note-taking style on memory retention and reflection,” she said. “In addition to seeking the excellent feedback from our peers to advance our own work, we are learning from our peers. Networking and building relationships with others across Canada is key to our ongoing success.”
Sita Bhella (Department of Medicine) presented a usability study on an online module she designed and created with colleagues in Toronto aimed at improving the knowledge and comfort of general internal medicine residents in managing sickle cell disease on the wards and in outpatient settings. “Presenting at CCME introduced me to new ideas and research methodologies and I hope to continue to present my work there in the future,” she said in an email. “It was an honour to present my work at CCME and to interact and engage with colleagues across the country on research in medical education.”
Kelly Howse (Family Medicine) presented both a poster and workshop. The poster explored issues of Family Medicine Resident Wellness: Current Status and Barriers to Seeking Help.
“Residency training can be a very stressful time and may precipitate or exacerbate both physical and mental health issues. Residents, however, often avoid seeking help for their own personal health concerns,” she said. “The purpose of this study was to assess the current status of resident wellness in our Queen’s family medicine program, with particular attention to identifying barriers to seeking help.”
The Seminar she presented focused on Supporting Medical Students with Career Decisions: National Recommendations for Medical Student Career Advising. “Specialty decision-making and preparation for residency matching are significant sources of stress for medical students. Through the FMEC PG Implementation Project, Queen’s led the development of national recommendations regarding the guiding principles and essential elements of Medical Student Career Advising,” she said. “This workshop helped disseminate these recommendations nationally and will help guide the exploration of relevant career advising resources.”
In addition to presenting their own work, School of Medicine faculty served as mentors for the many student presentations. Lindsay Davidson (Director, Teaching, Learning & Innovation Committee) shared “This year, I’m proudly watching some of our second year students present the poster that we collaborated on, Pre-clerkship interprofessional observerships: evaluation of a pilot project. It has been a pleasure to watch the students come up with the idea, which grew out of their own experiences as participants in a new inter-professional shadowing initiative for first year students, develop the project and reach conclusions that are helping to shape our teaching here at Queen’s. In addition to providing students with experience in conducting educational research, the partnership of students and faculty on such projects is a strength of our UGME program.”
So that’s a bit of what we’ve been up to in Montreal. Oh, and the food was great, too!
With thanks to everyone who was able to make time to send me some information, and apologies to all I’ve left out, especially given that I sent my email request on Friday when many were already in Montreal or enroute. Feel free to send me information I can add as an update (the beauty of blog over print.)
Five great reasons to attend medical education conferences
This weekend many involved in undergraduate medical education at Queen’s are heading to Montreal for the annual Canadian Conference on Medical Education (CCME). From faculty, to students, to administrative staff, we’re attending as presenters, workshop facilitators, and in several other roles.
As described on its website, CCME is the largest annual gathering of medical educators in Canada. Attendees include Canadian and international medical educators, students, other health educators, health education researchers, administrators, licensing and credentialing organizations and governments. The goal is to “share their experiences in medical education across the learning continuum (from undergraduate to postgraduate to continuing professional development).”
This year’s conference in Montreal from April 16-19 is hosted by the University of Sherbrooke (other partners are the Association of Faculties of Medicine of Canada (AFMC), the Canadian Association for Medical Education (CAME), The College of Family Physicians of Canada (CFPC), The Medical Council of Canada (MCC), and The Royal College of Physicians and Surgeons of Canada (RCPSC).)
With the theme is Accountability: From Self to Society, the program includes workshops, posters, oral presentations and plenary sessions designed “to highlight developments in medical education and to promote academic medicine by establishing an annual forum for medical educators and their many partners to meet and exchange ideas.”
Here are five good reasons we take the time from busy spring schedules to take part in this conference:
To present innovations in medical education at Queen’s: We’re doing some great things here at Queen’s and it’s great to share these successes. From early-adoption of the flipped classroom to our First Patient Program, to our Accelerated Route to Medical School – CCME gives a forum to celebrate what we’re doing well.
To learn from colleagues from other Canadian and international medical schools. While we share our innovations, it’s equally beneficial to learn from our colleagues at other schools. We don’t always have to reinvent the wheel.
To wrestle with common issues and gain comfort from being in the same boat. There’s a synergy in working together to sort out challenging issues in medical education.
To network with colleagues from across the country and around the world – this is closely related to both #2 and #3 – networking may not be about a specific challenge at a specific time, it’s making connections with like-minded individuals involved in similar circumstances.
And the food. OK, so this might not be a “good” reason to commit to attend a conference, but it’s certainly a fun part of it. Combining #4’s networking with colleagues with exploring local cuisine is an added bonus.
If you can’t attend this year, consider it for next time. Also, explore conference options closer to home. Our own Queen’s Faculty of Health Sciences Celebration of Teaching, Learning and Scholarship is coming up on June 15.
Artificial Intelligence? Artificial Doctors?
This past month, a software program designed to play an ancient game called Go defeated Lee Sedol, a South Korean gentleman who is an 18 time world champion, widely acknowledged to be the leading human player of the game.
The event didn’t attract much attention, probably because it was seen as a predictable, perhaps inevitable development. After all, computers have been capable of beating Chess Grand Masters for many years now.
However, if we pause for a moment and examine this a little more closely, we may find a deeper, more profound significance.
Go is a seemingly very simple game, hugely popular in the Far East. It’s played on a 19×19 grid of horizontal and vertical lines. Two players are provided with a bowl of either white or black stones. They take turns placing their stones on the points where the lines intersect. The object is to use your stones to claim territory on the board. Stones surrounded by enemy stones are considered “captured” and are removed from the board. The player with most stones on the board and territory wins. Play continues until somebody concedes.
The apparent simplicity of the game is actually quite deceptive. In chess, played on an 8×8 board with fairly restrictive rules as to how players can be moved, it’s been calculated that there are about 1047 different possible games that could play out. Although that’s a huge number, it is finite and therefore could be “solved” once computers developed sufficient processing power. Such programs are able to analyze any configuration of pieces and select options that will maximize likelihood of success based on an analysis of all possible outcomes.
The size of a Go board, and the simplicity of the rules mean that there are an enormous number of configurations and game possibilities. In fact, that number has been estimated to be 10170 (http://senseis.xmp.net/?NumberOfPossibleGoGames). That’s a number difficult to even conceive. To get some sense of its magnitude, let’s consider the following comparisons:
- Postulated time that has elapsed since the “Big Bang” (beginning of the universe) = 13.8 billion years = 4.335 x 1017
- Diameter of the observable universe = 93 billion light years = 8.8 x 1026
- Estimated number of atoms in the observable universe (according to Universe Today http://www.universetoday.com/36302/atoms-in-the-universe/): 1080.
So, suffice to say, 10170 is a pretty big number. In fact, it’s more of a concept than a number. Essentially, it’s infinity.
It’s difficult to understand what makes expert players succeed in a game so endlessly variable but, according to experts like Mr. Lee, it seems to be as much about creativity, spontaneous insights that emerge within a game, and much understanding of the tendencies of an opponent – all things we have considered to be uniquely human attributes.
What all this means is that the computer-based approach to the game must extend far beyond simply providing sufficient processing power to filter through possible outcomes. The computer has to develop what the programmers refer to as “intuition” developed through what they call (wait for this) “deep learning”.
Deep learning? From a computer?! Difficult for mere humans like myself to even grasp but it seems that, given enough processing power and enough historical game outcomes to review, the computer is able to analyze trends and resulting outcomes, eventually sorting through the “clutter” of countless individual human game experiences to develop principles, optimal approaches and even heuristic “rules of thumb”. In other words, it isn’t simply analyzing, it’s thinking.
Shortly after I’d read about Mr. Lee’s encounter with AlphaGo, I happened to overhear an interview on NPR between a rather enthusiastic computer programmer and somewhat bemused reporter. The programmer was making the case that the United States would be better off with an artificial intelligence President. In fact, he was making the case that this was inevitable within the next 15-20 years. Building on the success of AI approaches to complex games, he was making the case that a computer would be able to analyze all relevant facts, public opinions and historical events in coming to the most reasonable conclusion about any issue that might arise, and would do so without the various human frailties and inevitable personal/political influences that plague “human” political leaders. The interviewer, who seemed to initially approach the whole encounter in a humorous was, by the end, conceding that the AI “person” could at least serve as an impartial advisor to the human decision maker – for now.
All this raises some rather disturbing implications for the medical profession. Clearly, it’s not much of an extension to imagine artificial intelligence of this type finding its way to the development of “Artificial Doctors”. The ability to instantaneously consider all possible evidence, reference all prior outcomes and even “factor in” patient preferences without the nagging issues of personal distraction, fatigue or subconscious biases that plague mere humans seems hugely attractive, particularly when considering the emerging applications of robotic surgery and procedures. One can only imagine how governments and other funders who are struggling with the economic issues related to physician payment, might droll at the prospect of replacing physicians, or what they do, in this way.
This all begs the question, what will be the real value of physicians two or three decades into the future? Generations of physicians, to date, have earned their keep through their knowledge and technical expertise. As those commodities become available in alternative (and decidedly non-human) ways, what’s left? What “value” will mere human doctors provide? What implications does this have for the education we should be providing? I offer a few thoughts on this issue.
- It all starts with communication. Patients will always come as unique and diverse individuals with varying illness experiences. The ability to interpret their experiences in a way that will allow for the diagnostic and then treatment process to begin will always be rooted in a personal and human relationship.
- We will need more, not less basic science. A strong understanding in the underlying physiological and pathological processes that underlie disease and clinical presentations will continue to allow physicians to not only understand their patient problems, but also find creative and unique approaches to unusual or atypical presentations.
- Patients will always value the human interaction. Any study looking at what they value from their physicians prominently includes compassion and the personal interaction that they receive.
- Patients will need someone to advocate for them. Our health care system is complex, and this is likely to increase in the future. Patients will desire, and need, someone to help them navigate their illness experience. Our educational system should help medical students understand and learn how to utilize “the system” for the benefit of their patients.
Finally, it may all come down to a single word. “Care” is one of those interesting words that serves as both a noun and a verb. As such, it probably allows us a means to best describe the difference between artificial and human intelligence. Computer-based AI will, without question, be able to provide excellent, arguably superior, clinical decisions. However, they will never be capable of truly caring.
Vive la différence.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education