Month: December 2017
The Winter Solstice – Nature’s promise of better things to come
What do the Temple of Karnack in Luxor, Stonehenge in England, Chichen Itza in Mexico and Machu Picchu in Peru have in common?
Answer: They are all constructed, in part, to align with and mark the winter solstice. At Stonehenge, the central altar and “slaughter stone” are aligned precisely with the rays of the sunset on the winter solstice, the shortest day of the year.
The winter solstice, which occurs this week, is the day of the year with the least number of daylight hours for people in the northern hemisphere, and the most for those in the southern hemisphere. The exact timing of the solstice varies somewhat from year to year. This year, it occurs on Thursday December 21 at 16:28 GMT. It occurs because the vertical axis of the earth is not aligned perfectly perpendicular to the sun, but inclined about 23.5 degrees. This results in the hemispheres getting variable periods of daylight as the earth rotates during its annual journey around the sun.
There is much speculation as to why these various ancient civilizations chose to erect such monuments to mark the solstice. Clearly, they saw it as a pivotal event in their lives. They would have perceived the life-giving sun to be gradually withdrawing from their lives through the previous few months and then, on this particular day, and for no reason they could comprehend or control, re-emerging with the promise that life would continue once again.
Whatever their motivation, these structures should remind us that the peoples of the past were keen and respectful observers of the natural world. They recognized that the rhythms of the cosmos, even if beyond their understanding, were key to their survival. The ability to cultivate crops, find game and the essential need to store food and prepare for long winters was closely tied to their understanding of natural climate cycles. Observing the natural world was therefore not a casual pastime, but an essential survival skill. For these reasons, they were much more attuned to nature than those of us living in an era where, for most of us, technical advances have reduced diminishing daylight to a minor nuisance.
However, the solstice is in some ways a great leveler of humanity. It has been a feature of our collective life experience since human beings first walked the earth. It is also one of the very few events that occur at the exact same instant each year for everyone on the planet. It is therefore an event that transcends geography, culture, economic advantage, national boundaries, or even time itself. It links us all and reminds us that there are much greater forces at play in our lives than anything we can hope to control or even fully understand.
It also brings hope. It is the time of year when, through no effort, merit or intent on our part, light begins to re-emerge into our lives and, with it, the promise of new life in the spring. It is a time when, like nature itself, we should stop, rest and look hopefully forward.
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 new year.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
“To boldly go where no (Doctor) has gone before”
Those as nerdy as I will recognize the title of this article as paraphrased from the introduction to the original Star Trek television series. That program, set in a technologically advanced future, was about a long journey of discovery. Perhaps the most peculiar aspect of that journey is that it had no particular destination. The voyagers were simply wandering aimlessly, hoping to run into something interesting. Consequently, they often found themselves woefully unprepared for the challenges they faced – an excellent means to provide dramatic tension to a fictional story, but a dubious strategy for real life.
A medical school curriculum is basically a journey. For our students, it’s a journey that will take them into an unknown future. Like any real journey (and in contrast to the intrepid Star Trek crew), establishing a destination is the first, critical step. A long journey may consist of many stages and stops along the way that demand our immediate attention, but those stages are only meaningful if they move the traveler toward some ultimate goal. That goal, of course, is to become effective, fulfilled providers of medical care to members of our society.
The students currently in medical school will be practicing into the mid 21st century. If we’re to provide them an education that will best prepare them to make meaningful contributions, we need to give some thought what that world will look like, and what it will require of them as physicians and professional leaders.
This was the topic of a presentation and subsequent discussion at our semi-annual Curricular Retreat this past week. In preparing some remarks to begin that discussion, I attempted to draw on changes that have occurred in the course of my career and use those observations to extrapolate into the future. I came up with five that I think are particularly relevant. This is, by no means, a complete list, but perhaps sets the tone and the challenge.
In no particular order:
- The role of physicians as purveyors of medical knowledge.
Knowledge is the fundamental fuel of medical practice, and the commodity that gives legitimacy to those providing care. A generation ago, medical knowledge was elusive. It had to be searched out, a process that was paper based and time consuming. Physicians were the primary source and conveyors of medical knowledge. People who wished to become physicians went to medical schools largely to seek out the knowledge and skills that were embodied in the practicing physicians who taught there.
That has all changed. Medical knowledge is now available, almost instantly, who anyone who wishes to find it. Physicians are no longer the primary source of that knowledge. They no longer hold any monopoly on knowledge.
- The expanding applications of Artificial Intelligence and robotic technology.
We were all impressed when Watson defeated chess masters and Jeopardy champions. In my field of cardiology, I think many dismissed automated interpretations of electrocardiograms as simple algorithm-driven time savers that would always require physician verification. The same is happening with respect to interpretation of diagnostic imaging such as chest x-rays and CT scans.
But AI is moving far beyond these applications that are based simply on prodigious memory storage and processing capacity. Applications are becoming much more sophisticated and are developing the ability to learn and adapt to dynamic situations. Diagnostic algorithms are available that will provide reasonable differential diagnoses for patient presentations, and computer interfaces are under development that are frighteningly life like in their ability to interpret individual patient speech and even facial expressions.
Robotic applications in the operating rooms and procedure suites hold the promise of increasing technical expertise and consistency while reducing infection rates. They also allow for interventions in locations where the human hands are simply incapable of performing.
Extrapolating forward, it’s not at all hard to imagine a world where most diagnostic imaging and many therapeutic interventions will require much less, or perhaps no human intervention.
- Our fundamental understanding of human disease.
For generations, physicians have understood and characterized disease states based on what they could observe clinically. “Consumption”, “Whooping Cough” and “Scarlet Fever” are examples of conditions described solely on symptoms and visual inspection. As the ability to image patients and do laboratory analyses improved, patients with Consumption were found to have pulmonary damage caused by Tuberculosis, Whooping Cough became Pertussis and Scarlet Fever became associated with streptococcus infection.
I have lectured students for over 20 years on the classification, diagnosis and management of cardiomyopathies based on morphologic distinctions (Dilated, Hypertrophic, Restrictive) established by clinical examination and imaging appearances. My teaching is now changing, based on new classification schemes based not on morphology, but on the genetic mutations that result in abnormal development of cardiac muscle cells and channels.
This is not only highly appropriate, but promises to bring genetically based therapeutics that promise to alter the natural history of these conditions in ways currently not available. It also represents an entirely new science, involving genomics and an understanding of sub-cellular processes that practitioners of the future will need to understand and develop comfort with if they’re to provide optimal care.
- Standardized approaches to disease management.
Physician order sheets used to be blank and on paper. They have not only become electronically integrated into patient management systems of various designs, but have also become prepopulated with standard orders for many, even most, clinical conditions. Often, all that’s required are patient specific data such as body size and renal function, and a physician’s signature (real or virtual) at the bottom of the page.
This is good in the sense that it promotes consistent and evidence based approaches to these conditions, and reduces transcription errors. However, it can also diminish the educational experience of medical students, and may not fully account for the needs of patients with multiple medical problems or individual characteristics that require an individualized approach.
- Expanding role of non-physicians in health care delivery.
The widespread availability of medical knowledge in general and guideline based management strategies specifically has allowed for other health care providers, such as nurse practitioners, pharmacists and physician assistants, to participate more fully many situations. Another example from my field would be the expanding role of nurse practitioners in heart failure clinics. NPs are fully capable of managing the introduction and maintenance of standard therapies in this population of patients who often require close and continuing surveillance. They do so very effectively, and their participation has been shown to improve patient functional status and reduce hospital admissions.
And so, what to do…
It’s important to state from the outset that this is all good. These five changes will make health care more effective and efficient. Like any development they have potential pitfalls, but, appropriately managed, they will bring significant advantages to our patients. It’s also important to recognize that they are not going away. Technologic progress does not wait for us, or any group, to be ready.
And so, we must engage some very difficult and disturbing questions, summarized in this slide I presented at our recent retreat:
Obviously, there are no definitive answers, but I provide a few thoughts that emerged from recent discussions.
- Students no longer need to undertake medical education in order to locate knowledge – they are quite capable of doing that on their own. They do, however, require guidance as to what will be relevant to their careers, and an ability to interpret and evaluate the merits of the tsunami of information that will come their way.
- AI has the potential to dramatically improve the delivery of care, but can be highly threatening, partly because applications can develop out of context and without clear applications. Physicians of the future need to be more than consumers of AI, they need to involved in the development of applications, the purpose of which should always be to advance care. To do so, they will need fundamental education that develops familiarity with the technology and its potential.
- Medical education has always been rooted in science, but the nature of that science is changing rapidly. Fundamental knowledge about normal human structure and function will always be required, but will need to extend beyond the superficially observable to penetrate the genetic and subcellular levels of normal and abnormal human function.
- As Physicians are needed less and less to interpret test results or manage standard, well-defined clinical issues, their role will extend to ensuring patients enter the care system appropriately, and managing situations where the complexity or multiplicity of issues goes beyond standard management. This will require them to be even more acute assessors of patients at the primary presentation, develop high levels of sensitivity to patient outcomes that deviate from optimal, and have a depth of understanding of the scientific underpinnings of disease and system management that will allow them to step in and provide “customized” management when required. Indeed, “personalized medicine” may become the primary focus of the physician of the future.
All this, and no doubt much more, will require a vastly different approach to medical education, one that we need to begin to consider today. The future is closing in very rapidly. I’ll end with a quote regarding the future role of physicians from someone who was always technologically ahead of his time and not shy about expressing disruptive views:
“The doctor of the future will give no medicine, but will instruct his patient in care of the human frame, in diet, and in the cause and prevention of disease.”
Thomas Alva Edison (1847-1931)
Edison may have been somewhat overly optimistic about the “give no medicine” prediction, but was certainly perceptive in predicting fundamental change in approach. Over the next few months, we’re going to engage a series of dialogues about the doctor, and medical school, of the future, beginning with our recent retreat and this article. Please feel free to participate with your thoughts as we “boldly go” about charting a course into the next few decades of medical practice and education.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Queen’s Medicine Pre-Clerkship South East Asia Observership 2017
By Cesia Quintero (MEDS 2020)
In June and July of 2017, a cohort of six first year medical students from Queen’s University conducted a month-long observership in Vietnam and Cambodia. The goals of the trip were to provide the students with a valuable clinical experience and exposure to Global Health, and to establish connections that might expand the availability of Global Health experiences for future Queen’s medical students. We also hoped to explore the possibility of creating unique partnerships with overseas institutions that would boost the global profile of Queen’s University.
The bulk of our two-week Vietnam stay was at St. Paul’s Hospital in Hanoi, Vietnam, where we had a chance to observe in a variety of departments, including ICU, ER, Pediatric Infectious Disease, Pediatric Cardiology, and Endocrinology. Our visit was initially sponsored by the director of the Endocrinology department at St. Paul’s, and throughout our stay we managed to make good connections with several other physicians, including the director of the ICU. All of these physicians expressed interest in a similar arrangement next year. We also had a chance to have a one-day observership at the National Institute of Malariology and Parasitology (NIMPE), where we saw patients with parasitic infections that we would not have an opportunity to see in Canada.
The connections we made in this portion of the trip allowed for the possibility of more in-depth observerships at NIMPE in the future, and for expanding this opportunity to the National Hospital of Tropical Diseases. We also made connections that could allow us to similarly access the health system in the Lao People’s Democratic Republic.
During our Cambodia stay, we spent one week at Battambang Provincial Hospital, which is one of the larger provincial hospitals in the country, and at the Pailin Referral Hospital, a very under-resourced hospital that serves 75,000 rural residents. We quickly learned that Battambang Hospital routinely hosts students from Australia and the UK; during our stay there, there was a group of four medical students from the UK and 22 nursing students from Australia. Both the coordinator for foreign students and the director of the hospital indicated that they would love to form a relationship with a Canadian medical school. In Pailin we became closely acquainted with the Deputy Minister of Health of the province, as well as with the director of the hospital, and several department directors. At both Cambodian hospitals we spent our time in the ER, Pediatrics, Labour and Delivery, and OR.
In all of the hospitals, our role was strictly that of observers. The physicians who oversaw us facilitated a learning model in which the goal was for us to begin to recognize common signs and symptoms and gain first-hand experience with positive findings. Our activities consisted of observing patient care, impromptu mini-lectures from supervising physicians to illustrate relevant findings, and non-invasive supervised physical examinations. We were introduced to patients as foreign medical students by our supervising physicians, and in Battambang by our medical translator. We found that it was very helpful to point to our student IDs and highlight the word ‘student’ whenever it seemed that a patient was mistaking us for a doctor.
Throughout the day we did a lot of research on our own to answer any questions that came up. We found that having the ability to observe the same patients multiple times a day, several days in a row, was a huge advantage, as it allowed us to observe the progression of disease and treatment. For example, we had the opportunity to follow a patient with diabetic ketoacidosis from his admission to the ER to the ICU, and his eventual passing away, at each stage observing and researching the changing signs and symptoms, treatment efforts, and reactions from his family. We also found that seeing so many positive findings and performing so many physical examinations on actual patients greatly increased our confidence and clinical skills. Depending on our setting, we had the opportunity to observe a variety of procedures, including intubations, central line placement, wound care and debridement, deliveries and surgeries.
In all of this, we strove to be mindful of how busy and overworked the physicians were, and to operate by the principle that no patient experience or outcome should be negatively affected by our presence; if possible, we tried to be a positive presence for the patients. We are proud to say that we honestly believe we were able to live up to this goal. By separating into small groups, rotating departments frequently, and being independent learners for the majority of the time, we were able to avoid being a major burden to hospital staff. We also respected patient privacy as much as we could. Nevertheless in all hospitals there were a number of patients to whom a group of foreign students was an exciting event, and there were many occasions in which we thought our presence had been beneficial to a patient’s experience or outcome. In Battambang, a former soldier and his family burst into tears after some of us gave him a very respectful greeting in Khmer language; they said they had never received so much respect from someone in a white coat, and this was very meaningful to them. In Hanoi, we were able to comfort a very anxious ICU patient by listening to her heart several times a day when the physicians did not have time to attend to her emotional distress. There were multiple emergency situations throughout in which physicians borrowed our stethoscopes and other equipment, such as during a failed intubation.
It was in the understaffed and under-resourced Pailin Referral Hospital where there was the biggest opportunity for us to be a beneficial presence, and where one of the most impactful experiences of the trip took place. I went to check in on a TB patient who was faring poorly, and found that the physician on duty had not looked in on her for several hours. When I arrived, there were no nurses of other staff in the ward. She was alone, struggling to breathe, and her family was very distressed. I immediately phoned her admitting physician, who arrived minutes later. Nasal cannula were the only available tool to provide oxygen, but luckily we had a rebreather mask with us that could be connected to the oxygen tank. There were no monitors to keep track of her vitals, but we had brought a pulse oxymeter with us. When, despite the oxygen, her pulse and breathing stopped, three of us medical students were the only ones available to assist the doctor in performing CPR. The doctor himself would have been performing CPR without an N-95 mask if we had not been able to provide one to him. Unfortunately the patient passed away despite these efforts, but we were satisfied that our presence there had afforded her a better chance, and that at least her family witnessed medical staff making their best effort to save their wife and mother, who would have otherwise died alone and without medical help.
Global Health Experience
Due to the low-resource setting of these observerships, a lot of our learning went beyond the clinical. Both Cambodia and Vietnam are undergoing rapid economic development and demographic changes; the consequent epidemiological transition was highlighted time and again by physicians. We also witnessed the impact of patient crowding and severely exacerbated conditions due to lack of access. Particularly poignant were the struggles of physicians to provide medical care under extremely exacting conditions, such as limited resources and training, and political difficulties. We gained a better understanding of the multifaceted nature of these challenges, and of how difficult it is to bridge these gaps effectively. We also saw, however, that it is possible to make a difference. For example, we brought medical equipment with us that is currently filling some gaps at the Pailin Referral Hospital.
While all institutions that we visited expressed an interest in hosting Queen’s medical students in the future, near the end of our trip the director and several physicians at the Pailin Referral Hospital requested a meeting with us. They wished to explore the possibility of a closer relationship with our university. There were a variety of areas for collaboration that were proposed at this meeting, including the possibility of hosting clerks and residents who, unlike us, might be able to provide medical assistance to patients while being exposed to new situations and gaining useful skills. The director and staff indicated that the most critical needs for the hospital are 1) diagnostic equipment, and 2) advanced training for staff. The only imaging available at the hospital is a rather outdated x-ray machine that generates fuzzy images. In terms of training, their most emergent need related to the management of diabetes. Due to the epidemiological shift, widespread diabetes is a fairly recent phenomenon in rural Cambodia. Nevertheless, Pailin Hospital physicians estimated that currently up to up to 60% of their patients have diabetes. They are very motivated to improve their knowledge of and experience with managing this disease at such high frequencies, and asked about possible training methods they might be able to access, such as online modules or intensive training by diabetes specialists.
In response, we took notes of their concerns and promised to pass them on to the appropriate stakeholders at Queen’s Medical School. We also began independent efforts to find a digital x-ray machine for donation, and continue to look for ways to support the development of this hospital.
The trip exceeded our expectations in terms of the quality of clinical experience and global health exposure that was achieved, the receptiveness of our hosts to continuing this project, and the possibility for future in-depth, mutually beneficial collaborations at the institution level.
All photographs were taken for fundraising and educational purposes only, after obtaining informed consent from all parties.