Month: April 2017
“Why do you like baseball?”
I get asked this question a lot, mostly by those much younger than I – students, my children, nieces, nephews. It’s usually accompanied by an expression of pity that one would normally reserve for viewing the fossilized remains of extinct species. What they’re really wondering is “How could anybody in their right mind like baseball?”, or “Are you really that boring?”
I’ve often wondered myself, and have come to realize that, like most relationships, it’s complex and ever evolving. My grandfather got me started. He had two great passions beyond his family – opera and baseball. I remember visiting his sanctum – a small, dark, wood-paneled den filled with swirling pipe smoke where, settled in his overstuffed leather throne, he would watch a baseball game with the sound turned off while simultaneously listening to a recording of Pagliacci. I was never sure if the occasional tear in his eye related to the game or lyrics.
He immigrated from Italy in the 1920’s and settled initially with his wife and five daughters in Chicago. The opera he brought with him; the baseball he acquired as part of his new life. He loved to tell, with equal enthusiasm, of hearing Enrico Caruso perform and attending ball games at Wrigley. By the time he moved and settled in Huntsville, Ontario he had nine daughters (yes, NINE but that’s another story). I’ve often thought there was poetic symmetry in the number of daughters, the number of players on a baseball team and the number of innings in a baseball game, but he never claimed credit for the coincidence.
The daughters never intruded into the den while he was watching games but I was allowed to join him. At that time, I never really understood either interest. The grainy black and white images on the television screen didn’t hold much interest for me and seemed monotonous and slow compared to hockey games. The old phonograph recordings were scratchy and the lyrics didn’t make sense. The pipe smoke made my eyes water although I liked and can still vividly recall the smell of the tobacco. It was being with him that made it all worthwhile.
I was a reluctant recruit to both interests but, over the years have found myself, without deliberate intention, drawn to them. The opera might be considered a genetic inevitability. The baseball is acquired and harder to understand. On the surface, the young people have a point. Compared to other big league team sports, it’s slow and stuttering – monotony occasionally interrupted by moments of activity. Detractors love to note that during a complete baseball game, the actual active play only comprises about 10 minutes, but I’ve come to find that you have to scratch deeper to discover the charm and true depth of the game. It doesn’t give up its personality easily but, to the persistent observer, it reveals a character quite different than that of other so-called “major” sports. For instance:
There’s no clock. Baseball refuses to be governed by time. It’s over when it’s over, regardless of the hour. It eschews the concept of “clock management”, thank you very much.
It’s nerd friendly. No sport embraces statistics and relentless documentation of each and every event like baseball. There is an accounting and assigned acronym for every action and nuance in the game. True aficionados love to wallow in the numbers. And these statistics are not without meaning. “Moneyball: The art of winning an unfair game” by Michael Lewis is a fascinating account of how statistical analysis is being used effectively to change how players are selected and teams constructed. What all this means is that even those of us who aren’t gifted enough to play the game can understand what’s happening and comment with some validity. It brings together the athlete and the nerd and puts them on a more-or-less equal footing.
Personalities matter. In no game are individuals so much on display. Whether they’re pitching, batting, fielding or managing, there are moments in the game where attention is entirely focused on the actions of a single player, and there the outcomes are entirely dichotomous – success or failure. What becomes interesting is not whether they succeed or fail at whatever they’re doing, but how they respond to the moment. They become people with quirks and human reactions, not unlike those watching. And there’s the bound. Performer and spectator are brought together in this singularly human moment.
It’s quirky. The best nicknames: bar none. Consider: Catfish, Dizzy, Satchel, Pops, Smokey, Hammer, Sparky, Oil Can, Whitey, Yogi, Campy, Crabs, Eck, Gibby, Goose, Bambino, Mr. October, The Georgia Peach, The Say-Hey Kid, The Kentucky Colonel, The Splendid Splinter. And that’s just Hall of Famers. And the ballparks refuse to engage conformity. The Green Monster. The ivy at Wrigley. The brewery walls in the background of many outfields. Compare that to the obsessive conformity of football fields or hockey rinks. It all translates to personality and thumbing a nose at convention.
You don’t have to listen to it and watch it; either will do just fine, as my grandfather taught me so long ago. It’s also ideally suited to radio. In fact, it’s almost better.
It’s the most democratic of sports. Virtually anybody can play, and the game can be adapted and modified to fit the skills and energies of the participants.
It ain’t over ‘til it’s over. Hope springs eternal in baseball. Until the final batter makes the final out, there is always the potential for a team to come back from a deficit and snatch victory from defeat. In most other sports, points of hopelessness can develop where play becomes meaningless, but players are nonetheless required to go through the actions. An abomination.
It overcomes adversity. More than any other team sport, professional baseball has had its share of tragedies and miseries, all played out under public scrutiny. Segregation, corruption, betting scandals, the performance enhancing drugs debacle, have all tarnished its reputation and challenged the assumption of inherent innocence. In every case, the game has been the vehicle by which deep societal flaws have found expression and come to attention. As such, perhaps the game has served a purpose, reaffirming that the innocent are not immune from evil, but need not be defeated by it. Incredibly, improbably, it endures, scared but not broken, and arguably better for the experience. A metaphor for us all.
In the end, there’s a beguiling charm about a game that’s so quirky, unpretentious and stubbornly enduring. It survives despite the changes the world tries to impose. So, in answer to my young inquisitors, that’s why I like baseball. That, and memories of tobacco smoke, and Pagliacci.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Building Bridges, Making Pathways
By Denisha Puvitharan (Meds 2020), Darsan Sadacharam (Meds 2020) and Sahra Nathoo (Meds 2019)
Twenty-four curious high school students joined the ranks of diligent medical students in the halls of the Medical Building on March 31st. These students were taking part in the first ever “Pathways to Medicine” event hosted by Queen’s School of Medicine’s Diversity Panel.
Through a new partnership with a local chapter of a national organization, Pathways to Education, the panel organized a full day event aimed at increasing interest in a future career in medicine among students engaged with Pathways, along with some students from Immigrant Services Kingston and Area (ISKA).
Participating students heard from Dr. Michelle Gibson, Director of Year 1, who introduced them to the day. They participated in a small group learning session with Dr. David Bardana and the class of 2020, clinical skills training with tutors Drs. Rick Rowland and Nicola Murdoch, and resuscitation simulation and laparoscopic training sessions with residents, Drs. Kristen Weeksink and Gary Ko, during their visit. Dr. Mala Joneja, Director of Diversity in UGME, sped them on their way with inspiring words. The inaugural “Pathways to Medicine” event was an excellent teaching and outreach event that was highly praised by all staff and students involved.
The Diversity Panel is an interdisciplinary team of interested students, educational staff and faculty, which exists to improve undergraduate medical education at Queen’s, through increasing diversity and making careers in medicine more accessible to those from underrepresented populations. There have been many conversations regarding the importance of medical student bodies representing the diversity of the patient communities they will serve in the future. In addition to the upstream effects of making the healthcare profession more adept in providing quality care to the existing diverse population, increased physician diversity is also particularly important when considering the physician shortages that low income neighbourhoods face in Canada. By enticing more students from these neighbourhoods to attend post-secondary education and medical school, there is an increased likelihood they will return to practice in these neighbourhoods, thus helping relieve some health inequities.
Though many efforts have been made to make medical school more accessible to students from lower socio-economic backgrounds, many barriers remain. The cost of medical school alone is astronomical, when considering the tuition for an undergraduate degree, MCAT registration fees, application fees, and potential income-earning hours spent studying; students from low income families are already discriminated against. Attempting to address these concerns, the Pathways to Medicine event also included a presentation on financing medical education by Ms. Margie Gordon from the Registrar’s Office, specifically regarding OSAP, grants and other resources available to help these students reach their goals.
However, when making efforts to increase the accessibility of medical school for students from diverse socioeconomic backgrounds, the true challenge is in leveling the playing field at the starting line for these students. From the onset of a student’s educational journey, his/her family’s financial and social resources can play a significant role in dictating their success. Strong financial support can assist a student’s ability to excel in school, while also participating in various extracurricular activities, which can benefit the student in future endeavours. Furthermore, students from higher socioeconomic backgrounds are privy to strategic knowledge of what it takes to become competitive applicants as a result of having access to various social resources. These resources can come in the form of connections with academics, physicians and others that have experience navigating the application system. An anecdotal example of how strong social resources can provide an advantage to students is provided by Dylan Hernandez’s opinion column in the NY Times.
“Pathways to Medicine” represents Queen’s UGME Diversity Panel’s continued efforts to find creative strategies in addressing this complex challenge. Although this may be a small step towards addressing these barriers, it is our hope that through events like this and other similar initiatives held at medical schools across Canada, students from diverse backgrounds may soon see medicine as a realistic goal.
Unintended casualties of Medical Assistance in Dying
There shouldn’t be much more to say about this subject. The highly contentious and divisive issue of medical assistance in dying (MAID) has been widely and publicly discussed. From a legal perspective, the issue has been settled in Canada. Citizens can now opt to have their lives ended given they fulfill certain criteria. The medical profession and our hospitals have an obligation to support patients who qualify. Individual physicians who chose to actively end the lives of these patients will be legally protected in doing so. Those who conscientiously object are not required to provide MAID but are professionally and ethically required to support their patients in making the decision and seeking the service, which is now being provided, both in and out of our hospitals. There would seem to be no need for further debate or discussion.
However, little has been written about the impact on those involved in the care of patients opting for MAID.
I’ve recently been hearing from medical students who, in the course of clerkship rotations, became involved with patients who elected for medically assisted death. They have found the experience, to say the least, highly unsettling.
For those readers not familiar, senior medical students, in the course of their clinical placements, will become part of medical teams caring for groups of hospital in-patients. The medical student is the most junior member of that team, consisting of graduate physicians training in particular specialties and supervised by a fully qualified Attending Physician. The student is assigned a small number of patients who they are expected to assess and follow throughout their hospital stay. They report regularly on their patients to senior residents and the Attending Physician who review the patient with them and must approve all investigations, treatments and major decisions.
In the course of these rotations, medical students get to know their patients quite well. In fact, they may become the member of the team most familiar with all aspects of the patient’s history and current care, most familiar with the patient as an individual, often even meeting their family, and may become a source of support and information to the patient and family. In short, they “bond” with their patients. Because these are the first such experiences for medical students, these relationships can be quite significant for them, and very memorable. Most practicing physicians can recall with considerable detail and deep feeling patients they encountered as medical students.
When a patient assigned and followed by a medical student dies, it can therefore be quite an emotional experience for the student. They can experience a sense of very personal loss. They grieve. When that death occurs as a consequence of the medical illness under treatment, that loss and associated grief are difficult but valuable components of the learning experience. They understand that this is something that every physician must learn to deal with. Doing so is a part of professional development that must be experienced. In the learning context, senior members of the team can support them by sharing the sense of loss and their own experiences. Within the medical school environment, they can also seek help from knowledgeable and experienced advisors and counselors.
Medically assisted death brings new dynamics and challenges to physicians involved in the care of the patients.
Although always prepared intellectually for the eventuality of death as a consequence of illness, students (and qualified physicians) are not prepared either intellectually or emotionally for the concept of deliberately ending a patient’s life, even if they’re not directly involved in the final act. Coming to grips with this in the abstract is one thing, but encountering it in a person one has engaged as a patient and has gotten to know personally is quite another. No one engages medicine as a career with this purpose in mind.
We teach and practice that medical care should continue throughout a patient’s life, and that compassionate attention and care to a patient’s needs and comfort should not stop when cure is no longer possible. Participation in MAID seems, for many, very difficult to reconcile with that approach, even when carried out at the request of the patient.
Medical students on clinical rotations who have been involved with MAID situations, I’ve come to learn, are particularly vulnerable. There are a number of reasons for this. They may be reluctant to express and undertake “conscientious objection” out of fear of being seen as weak or inadequately trained. They may not be aware of that option. They may not yet be clear about their own perspectives on the issue or reactions to these situations. They are young, and for many these may be their first experiences with professional or personal loss. The playing field, therefore, is far from even.
Moreover, supervising physicians and residents who are themselves engaging MAID for the first time may be coming to grips with their own involvement and therefore uncomfortable and unprepared to counsel students involved in these situations.
For all these reasons, we need to give some consideration as to how we can best support students as they (and we) come to grips with MAID. This will involve ensuring:
- They understand the legislated rights of patients
- They understand the ethical/professional obligations of physicians
- They understand the procedures in place to provide MAID in their hospitals and communities
- They learn of the needs and how to best support patients with chronic pain and other end-of-life challenges
- They understand that when patients under their care die, they will experience a personal reaction they won’t be able to fully anticipate until it happens.
- That they know how to seek help to deal with these situations.
We also need to ensure our residents and faculty are aware and prepared to respond.
There is a danger that raising such concerns may be regarded as callous to the suffering of patients with terminal diseases, or opposition to their right to choose an option that is legally available to them. That is not the intention. The right to assisted death has been legally provided and should be honoured. However, the well-intentioned efforts to provide MAID has placed new and impactful demands on physicians and learners which were either unanticipated or ignored. We must consider these consequences as we come to grips with how this legislated right is to be provided.
In the end, there is something profoundly dissonant about expecting that those who have dedicated their lives to preserving life will also participate willingly in ending it, and without personal consequence. There is a price to be paid, and that toll may be falling on the most vulnerable among us.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
The Value of Medical History
By Sallya Aleboyeh, MEDS 2019
A group of passionate and curious medical students chose to venture to Ottawa on the Family Day weekend this past February. Instead of visiting their families, they dove into history, with a group of equally-passionate curators and assistant legislators to Elizabeth May who also gave up time to give us private tours of:
- The Preservation Centre in Gatineau, which houses vaults filled with paintings, media and lots of important archives
- The Museum of Science and Technology’s Storage Facility (which is apparently cooler than the museum itself)
This year was the final time Dr. Jacklyn Duffin, Hannah Professor in the History of Medicine, organized the history of medicine trip, making the fate of future trips uncertain. So instead of telling you how cool everything was (hopefully the photos can show that), I thought I’d share the value I see in keeping the tradition alive.
1. Cool Architecture: The Role of design, décor and architecture in medicine
Arriving at our first stop, the Gatineau Preservation Centre, what stood out most was the architecture. The vaults were inside a huge cement box that looked like the set of a parkour film; while the top floor, where restoration was done, resembled a Lego village complete with primary colour paints and street names for corridors. Whether you cared about the science behind restoring artifacts or not, the design was very hard to ignore.
On a day-to-day basis, physicians not only interact with patients, but with their environment as well. While it’s not practical or financially viable to have an architect design each hospital as a unique piece of art, the impact of space is large enough to warrant investing some thought. There are already lots of examples of environment helping with patient or doctor experiences:
- Having windows in the ICU rooms to help with delirium
- Having paintings/magazines in waiting rooms to make wait times seem shorter
- Having healing gardens to reduce stress for patients and health care workers
- Having cartoon characters on walls in children’s hospitals
- Having the nursing station in the middle of a room, visible to all patients, to reduce anxiety
- Decorating your office with pictures of family to make working there more enjoyable.
(for more evidence of the importance of environment in health- check out this NYT article here!)
Obviously, during an emergency, it won’t matter how aesthetically pleasing the sheets or walls are, but the vast majority of hospital interactions with patients and among health care workers aren’t immediately urgent. In these instances, a little interior design can work its subtle magic on people’s mood and their interactions because we all (I think) appreciate pretty things. It’s why chefs create garnishes and why companies invest in packaging. In the long run these small effects can add up to increase overall wellbeing and happiness.
2. Studying History is humbling and reminds you that your actions might outlive you
If you’ve ever been to a really old place, you’ll know that you get a strange surreal feeling, like you are experiencing something bigger than yourself (hopefully it’s not just me). When I was 16 and my mom took me to the ruins of Persepolis (wiki: “the ceremonial capital of the Achaemenid Empire”) and I felt it for the first time while trying to imagine what it looked like thousands of years ago before Alexander attacked it. It reminds you at once of how insignificant you are and how capable you are of creating something that can last for generations after you are gone.
The profession of medicine can be demanding: long hours, bad news, on call shifts, high stake decisions and emotional fatigue to name but a few. It’s in these moments when remembering that you’re working towards something bigger helps. One day when we’ve all left this planet, curators, historians and medical students may look through the ultrasound machines, pacemakers and lounge room coffee machines we used and try to uncover the story of our daily lives. We can’t predict which of the thousands of items we see and use in our lifetime will survive as artifacts, but we can choose what kind of story they tell.
3. History is full of lessons and wisdom
Finally, most important of all is that history is an endless resource of wisdom and lessons. We constantly look to our tutors, teachers and mentors for guidance for medicine because it’s easily accessible; but why stop there?
From history you can learn to be creative, and to draw inspiration from new places. Over the course of the weekend, we saw multiple examples of technology from other industries being adapted to medicine.
- The cloth used to make sails being used as a backing for fragile paintings
- Ultrasound machines being used to detect aircraft defects and in the navy before being applied to medicine
- The Fibroscan for the liver coming from cheese manufacturing (I technically learnt this in class after the trip but it helps prove the point)
History’s mistakes teach us to not just accept what we’ve been told but to dig deeper and ask questions because things may not be what they seem. During our visit to the Storage room, the curator’s personal research on artifacts in the storage revealed that Sir William Osler – a great Canadian medical teacher – may have used the remains of aboriginal bodies for research purposes. Another inquiry led the curator to discover that models of babies with syphilis were used to promote eugenics and not medical education as previously believed. If we remain passive in our learning and acceptance of new information, it’s often the patient who will pay the price.
(In conclusion) I hope there will be many more history of medicine trips to come because there is still a lot that history can teach us (and lots of cities to be seen) before we begin our practices.
A version of this blog post appeared previously on the Medicine and Literature blog. Find it here. Thanks to Sallya Aleboyeh for her permission to repost it here.
The Creative Spirit in Doctors: Medicine’s Two-edged Sword.
Over two full and very busy weekends in March, about 600 young people from across Canada are invited to Queen’s to apply for admission to our medical school. As they do so, they are welcomed, guided and encouraged by our first year class. Part of their welcome to our school is a video they screen for the applicants and their families, intended to entertain, but also to give some sense of our values and identity as a school and community. That video, essentially a fairly sophisticated mini-musical, is written, performed and produced entirely by members of the first year class. In fact, almost every member of the first year class is involved in some way in the production process.
Later this week (April 7th and 8th – get your tickets), our students will be putting on the latest version of Medical Variety Night “The Phantom of the Operation”. Anyone who has attended one of these productions in recent years will realize it has become much more than satirical commentary and slapstick humour (although both are still very much in evidence). MVN has become a showcase for the considerable musical and creative talents of our students, from sophisticated dance to rather impressive musicianship. In fact, as you get to know our students, you will find that a surprising number of them have deep interest and maintain active involvement in artistic pursuits. In many cases, there’s almost a reluctance to admit to such interests, perhaps fearing it may suggest a lack of focus or dedication to their burgeoning medical career.
This deep-seated interest in the arts extends to our faculty, for whom it may be submerged or “put on hold” but never fully suppressed. In the Department of Medicine, several members
have combined their musical talents to form “Old Docs, New Tricks” which, it seems, brings as much satisfaction to the performers as those they entertain. I happen to know a certain department head and accomplished career scientist who is a remarkably gifted classical guitarist. A cardiovascular surgeon acquaintance of mine “moonlights” as an operatic tenor. Even if not actual performers, many of the great physicians I’ve encountered and gotten to know well over the years have deep appreciation for literature, music and the arts.
This shouldn’t come as any surprise.
Albert Einstein, who had a lifelong and active interest in the violin said:
“If I were not a physicist, I would probably be a musician. I often think in music. I live my daydreams in music. I see my life in terms of music.”
Largely self taught, he also observed “love is a better teacher than a sense of duty.”
Winston Churchill possessed a remarkable creative energy that found expression in multiple ways. He was a prolific amateur painter, and also enjoyed bricklaying fences, gardening and breeding butterflies at Chartwell. His two great literary contributions The Second World War and A History of the English Speaking Peoples read not as dry historical accounts, but as personal memoirs written in a highly engaging narrative.
Scratch the surface of greatness, it seems, and an artistic temperament usually emerges.
So is all this just coincidental? Do bright people just naturally engage multiple interests, or is there a connection between career success and a creative, artistic personality? Are there particular lessons here for the medical profession, and for medical education? I’m sure there are many, but I would highlight three:
Creativity is creativity.
Whether it is conveyed in music, words, or scientific innovation, the expression of new ideas, or interpretation of existing ideas in fresh and unexpected ways, is the essence of the creative process. This does not apply only to research. Because every patient and every clinical situation presents unique challenges, the effective physician is required to continually develop creative approaches. Our best administrative minds are able to “think outside the box”. Algorithms, practice guidelines and standard approaches can only take us so far.
It broadens our appreciation of the human experience.
Creative art, in any form, is fundamentally an attempt to express some aspect of the human experience, and hold it up for all to see, consider and learn from. David Skorton, a cardiologist (and jazz flautist) who is currently head of the Smithsonian Institution perhaps expressed this best in an impassioned keynote address at the recent annual meeting of the American College of Cardiology entitled “Medicine Needs Art to Flourish”.
“There is a reason we hang art on our walls and venture out to hear live music and watch theatrical productions. There is a reason the words of Shakespeare or Angelou or Springsteen move us. There is a reason we gather in temples, cathedrals, libraries and museums. The reason is that we learn fundamental truths about ourselves.”
Those truths, I would argue, are critical to the practice of medicine.
It promotes wellness.
At the risk of being overly simplistic and offending those much more knowledgeable in such matters, let me simply say that I believe the creative process is good for us. There is something fundamentally and rather profoundly satisfying about producing something new and uniquely personal. Whether it’s music, performance, creative writing or whatever doesn’t seem to matter. It doesn’t even matter whether it is carried out privately or very publicly. Creative expression somehow connects us with ourselves and with the world in a way that is validating and allows us to better face all our various challenges. We need it. We crave it. It’s almost intoxicating. If you need convincing, watch the expressions and body language of students or physicians as they engage their various artistic interests. Consider how many immensely talented young people engage careers in the arts with little prospect of personal security, or even opportunities to indulge their passion. Again quoting Einstein, who knew a thing or two about the creative process, “I know that the most joy in my life has come to me from my violin.”
So the advantages seem obvious. A creative mind and artistic spirit provide an ideal starting point and are quite probably essential to learning and practicing medicine. It could even be considered quite natural that creative thinkers will be drawn to careers in medicine. But, as with most natural processes, there are counterpoints, or consequences to consider.
The artistic spirit follows its own path and naturally resists external control. Since the profession so often attracts these free and independent thinkers, developing consensus and unified approaches to controversial issues can be hugely challenging. This reality is in rather public and painful display in Ontario at present and, I’m sure, at any department or practice group meeting. Doctors will never be found marching lockstep for any cause, or at least not for long.
Leadership within the medical profession is therefore a considerable challenge for those who bravely take on such positions. To be effective, that form of leadership must be much less about exerting authoritarian control and much more about harnessing and nurturing the considerable creative and highly-motivated energy available. That harnessing and nurturing takes interpersonal skill, patience, energy and self-sacrifice, a rare but very valuable combination of attributes.
The other unfortunate consequence of an artistic spirit engaged in work that demands high level performance of repetitive tasks is restlessness. Creative minds require continual and changing challenges. Put simply, they get bored doing the same thing, even if that thing is critically important and demands perfection. Failure to recognize this, I would conjecture, leads to job dissatisfaction and what we might identify as “burn out”. On the other hand, recognition of this issue by both the individual and those in leadership positions can provide opportunities to harness that creative restlessness and use it to great advantage, salvaging careers while strengthening groups and institutions.
So the artistic temperament can truly be regarded as both a great advantage and potential liability for the profession. Like the metaphorical two-edged sword (or scalpel), it can be very effective, but must be grasped carefully and handled skillfully.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education