Month: November 2018
KHSC Nominations open for Exceptional Healer Awards
Nominations for the third iteration of the Kingston Health Sciences Centre (KHSC) Exceptional Healer Awards are open with a deadline of December 14.
Launched in 2017, the Exceptional Healer Awards are sponsored by the KHSC Patient & Family Advisory Council and was designed to honour a physician who demonstrates in clinical practices the core concepts of patient- and family-centred care: dignity and respect, information sharing, participation, and collaboration.
Prior honorees include ophthalmologist Dr. Tom Gonder and anesthesiologist Dr. Richard Henry (2017, tie) and urogynecologist Dr. Shawna Johnston (2018).
The award has been expanded this year to include one for physicians and one for nurses.
Physician nominees must, as a faculty member at Queen’s, have a current appointment at KHSC and have been credentialed at KHSC for at least the past two years. Nurse nominees must be KHSC staff members.
Patients and family members can nominate a KHSC physician and/or nurse who have provided care to them in the last two years while KHSC staff can nominate a physician and/or a nurse on a patient care team.
The awards committee is looking for nominees who:
- Demonstrate compassion as a skillful clinician by displaying personal qualities such as approachability, flexibility and empathy
- Use novel or innovative methods in attempting to deliver compassionate care
- Demonstrate a pattern of listening to and honouring patient and family perspectives and choices
- Exhibit a value of integrating patients and families into the clinical care model to ensure they are equal, informed participants in their health care
- Honour the uniqueness of patients and families by incorporating their knowledge, values, beliefs and cultural backgrounds into the planning and delivery of care
For the 2018 award, patients, families and staff nominated 21 physicians for the award. Thirty-four nominations were receive, with about 25 percent coming from KHSC staff.
Medical students and nursing students are eligible to submit nominations in the “staff” category.
Further information and links to the nomination forms can be found here: http://www.kgh.on.ca/healer
The stories we tell…
I’ve been thinking a lot about stories lately.
It’s partly because of an independent study I’m completing at the Queen’s Faculty of Education on narrative inquiry. It’s partly because I’m increasingly conscious of several aging family members whose stories I want to record—and of other members whose stories have been lost. It’s partly because I’ve watched some excellent biographical documentaries on Netflix recently. It’s also partly because I just love good stories.
As an educator, I embrace stories and that’s easy to do since we’re surrounded by stories: The stories we tell. The stories we hear. The stories we learn—and learn from.
We all have stories we’ve seem to have known forever that we know we will share and pass along. This is because stories are personal, usually relatable, and “knowable”—it’s a way to memorize without strict rote memory.
We tell stories to impart lessons, to entertain, to remember. And sometimes all three.
Like the story I tell of leaving a political science essay to the last minute when I was in my second year at the University of King’s College. The one I stayed up until 3 a.m. writing, then got up at 5 a.m. to type it (on my electric typewriter, no personal computers in those days). It was on the Cuban Missile Crisis. Except in my sleep-deprived state, I didn’t type it that way. Instead, I wrote of the Cuban Missal Crisis.
And my professor circled “missal” every single time it appeared through the paper. (Which was a lot). I respected this man profoundly and his was my favourite course. I was mortified when he returned the papers and I saw all the circles (every single time). Still, he gifted me with a B+ (which was rare for him), so the content, if not the spelling, was fairly sound.
Why do I tell this story? (1) It’s kind of funny. (What would a Cuban missal crisis look like? Too many prayer books? Too few? Typos within them?) (2) It cautions against procrastination. (Which is why I shared it with my daughter when she started university and use it to remind myself, constantly). And (3) it advocates good proofreading – which we should all do, all the time. Plus, it’s relatable to many who have “pulled an all-nighter” who nod and smile through the telling (or reading) of this anecdote.
Medicine, and medical education, relies heavily on stories. Every medical encounter I’ve had as a patient has started with my story – what brought me there. Taking patient histories is one of the first clinical skills our students undertake.
What are case studies if not stories? Some are bare bones, some rich and colourful in detail. Like patients. Like people. We can’t see (or read) all, but we can see (read) enough. Stories are entrées into another person’s life, their point of view, the path they are on.
What goes into a good story? There’s characters, and place, and time, and plot – something has to happen. And woven into this, deliberately or incidentally, is meaning.
Stories can be loud “A-HA!” moments, or a gentle unfolding. They can be meandering streams-of-consciousness (perhaps a bit like this blog post), or a clear, linear narrative. Or something in between.
The best stories are conversations. What are the stories you tell? What stories will be told about you? As a student, as a teacher, as a person?
Do you have a story you want to tell related to medical education? Drop me a line at firstname.lastname@example.org – it may fit here in our Guest Blogger posts.
What stories do you want to tell?
Patients are key to our students’ learning
Students have been part of my health care journey long before I became an educational developer at Queen’s School of Medicine.
When my daughter was born in 1995 in Fredericton, NB, I had not one but two nursing students from the University of New Brunswick assigned to me. For each of them, I was their first ever patient. I was also their only assigned patient. As a first-time mom, this was both gratifying (they pretty much catered to my every need from running baths to making me snacks) and faintly terrifying (like when they, under their preceptor’s watchful eye, demonstrated to me how to give my newborn a sponge bath) and slightly uncomfortable (post-partum abdominal palpations aren’t fun at the best of times, let alone by a learner who isn’t quite sure what they’re looking for).
My mantra at the time was: “They have to learn somewhere – why not with me?”
And it’s true – there’s only so much to be learned in a classroom, a mock clinic, or simulation lab. Ultimately, our medical students consolidate all that learning during their two-year clerkship period where they engage with real patients, in real hospitals and real clinics, supervised by staff and resident physicians.
In my role as an educational developer, this is a part of their education that I don’t typically see first-hand. I’m generally classroom-based in the coaching I provide to faculty, and it’s hard to be an unobtrusive fly-on-the-wall observer of patient encounters when you aren’t a member of the healthcare team.
As a patient (and parent of a patient, and partner of a patient), however, I’ve had several opportunities to see our clinical clerks in action first hand.
I’ve watched a senior clerk valiantly (and ultimately successfully) conduct a physical exam on my pleasant-but-non-cooperative then-nine-year-old son.
I saw another clerk—working on a rotation with anesthesia—get a reluctant laugh out of my grumpy (from fasting) and nervous (because, well, surgery) husband during the pre-op airway examination and checklist.
Most recently, one of our clerks independently led off an appointment I had at my family physician’s office. I’ve hit a milestone birthday (full disclosure: 50) that can trigger a number of screening tests and things. The clerk was well-prepared, asked me good questions, and had good information. It was clear to me that they had at least scanned my file before coming into the room and had done their homework on the types of screening tests that might be relevant to me.
Along the way, I’ve also seen some of the various ways the clinical clerkship preceptors supervise and monitor our students’ learning.
For the clerk who examined my son: after a consultation outside the exam room, the clerk and physician came in together for the rest of the appointment. There was a Q&A amongst all of us which included gentle coaching and good feedback for the clerk.
Prior to my husband’s surgery, after the clerk’s exam, the anesthesiologist followed up with their own exam and pointed out a couple of things to the clerk – who then had another look down my husband’s throat which they and the physician then discussed.
For my encounter, I know my clinic has video monitoring (as there are signs posted in the examination rooms) and the clerk themselves noted they were going out to consult with the physician.
These are all different ways that clinic-based teaching and learning takes place. And that’s due in large part to patients who willingly engage in these encounters. As part of the UGME team, I feel a certain obligation and responsibility for their education and training. Most other patients don’t have this same motivation and it’s their generosity that makes this learning possible.
Through not only their classroom based studies, but especially their clinical skills training over two years, their simulation lab work, and our First Patient Project, our students are ready to engage with patients and be part of the healthcare team in their clerkship years. A sincere thank you to patients in Kingston and at our regional sites who engage with them as they learn.
Engaging Disruptive Innovation. The evolving role of POCUS in clinical medicine and medical education.
Who among us didn’t get through high school without regularly reaching for a well-thumbed encyclopedia plucked from a shelf in our parents’ basement or local library reference room? Not me, to be sure. Whether it was how rubber is manufactured, legislative accomplishments of a long-deceased prime minister, or the agricultural exports of Guatemala, the encyclopedia could always be counted on to provide reliable information, in time for whatever deadline was looming.
The word “encyclopedia” itself has an interesting and revealing etymology. It apparently contains elements of word origins for “circle” (interpreted to mean “complete” or “all-inclusive”), “child” and “education”. We all know the word to refer to a comprehensive, single source that brings together diverse information. An encyclopedia is a one-stop-shop for a little bit of everything you might need to know about anything.
The most venerable example is Encyclopædia Britannica, first published in 1768 (https://www.britannica.com/topic/Encyclopaedia-Britannica-English-language-reference-work). The 2010 edition consisted of 32 volumes and 32,640 pages. It was written by about 100 full-time editors and more than 4,000 contributors. Contributors have included Nobel laureates and five American presidents.
That 2010 edition version was its last print edition. After 242 continuous years, Encyclopedia Britannica went out of the print business. It was a victim of what has come to be known as Disruptive Innovation.
That concept emerged in the 1990s and is most commonly attributed to Clayton M. Christensen who has written extensively on the topic as it plays out in the business world and explains the rise and failure of various enterprises.
In a 1995 Harvard Business Review article that is well worth the read (https://hbr.org/1995/01/disruptive-technologies-catching-the-wave), Christensen defines disruptive technologies in the following way:
The technological changes that damage established companies are usually not radically new or difficult from a technological point of view. They do, however, have two important characteristics: First, they typically present a different package of performance attributes—ones that, at least at the outset, are not valued by existing customers. Second, the performance attributes that existing customers do value improve at such a rapid rate that the new technology can later invade those established markets. Only at this point will mainstream customers want the technology. Unfortunately for the established suppliers, by then it is often too late: the pioneers of the new technology dominate the market.
The disruptive innovation that lead to the demise of print versions of Encyclopedia Britannica was, of course, Wikipedia. It provided an easily accessible, comprehensive and continually updated source of information at no direct cost to the consumer. The fact that it lacked historical status, cachet or even a reputation for the accuracy of its sources was glossed over by the consuming public who were very willing to set aside all those considerations for the convenience and economic advantages.
Disruptive Innovation, almost by definition, upsets existing patterns of practice or behaviour and resets the way people go about a common task or access a service. There is always a reaction from those involved in the traditional paradigm, usually characterized by statements such as
“what’s the proof this is better”
“there’s no problem with what we’re doing now”
“it hasn’t been fully researched”
“there will be unintended consequences”
The disruptive innovators, for their part, have the courage of their convictions. They believe they understand market forces better than the established providers, and are willing to gamble that they’re right. Basically, they believe in letting the market decide.
The medical world, of course, is certainly not excluded from disruptive innovations. In fact, it has benefited greatly, but not always willingly. An example I’m very familiar with from the cardiology world is Percutaneous Coronary Angioplasty. When first introduced by Dr. Andreas Gruentzig in 1977, this innovation truly set the cardiovascular world on its collective ear. Prior to that, therapies for coronary occlusive disease were limited to medical therapies (provided by cardiologists) and coronary bypass surgery (provided by cardiac surgeons). The dichotomy and division of labour were clear and well accepted. The catheterization laboratory was a place for diagnostic investigations to determine the extent of disease, not a place for therapeutics. Gruentzig’s innovation completely upset the existing paradigm. Moreover, it put the interventional cardiologists in the driver’s seat, because they could link the therapeutic intervention to the diagnostic procedure, therefore engaging the issue first and therefore, potentially, circumventing the role of the cardiac surgeon. The simple intuitive appeal of being able to dilate an obviously obstructed vessel without the need for even a second interventional procedure, much less surgery, was powerfully compelling, and both the medical community and patients were very willing to set aside the usual and well-established need for controlled comparative trials before embracing this new technology enthusiastically.
The development of Hand-Held Ultrasound (HHU) and its clinical counterpart, Point of Care Ultrasound (POCUS), could be considered further disruptive innovations facing the medical community. Ultrasonic imaging, by virtue of its ability to provide information on a variety of structures in a non-invasive, non-toxic manner and at relatively low cost, has taken on a key role in medical diagnostics, ranging from cardiac (where it is known as Echocardiography) to abdominal, thoracic and vascular imaging. It was initially provided only with large and complex machines that were not easily transported, and provided images and measurements which were imprecise, difficult to obtain and required “expert” recording and interpretation. The technology therefore required third party interpretation and consultation before results could be reliably utilized to guide patient care.
Over the past decade or so progressive technical advances have made it possible to obtain excellent quality images from small devices that can be carried easily and used at the bedside. This technology is such that it can be used by an individual to guide the diagnostic approach and decision-making process, analogous to how physicians use stethoscopes. Although the HHU technology is not yet able to provide the full package of information that would allow it to completely replicate the comprehensive examination, it’s not unreasonable to expect that will occur in the not-too-distant future.
In addition to challenging the role of ultrasonic imaging as a diagnostic procedure, this technology is also challenging our approach to the clinical examination in medical school, where students and educators are asking very valid questions as to the role of these “competing” technologies.
I recently participated in a symposium at the Canadian Cardiovasular Congress recently exploring this very topic. Together with my colleague Dr. Amer Johri, as well as Dr. Sharon Mulvagh from Dalhousie, Dr. Rob Arntfield from Western University, and our former Echocardiography Fellow (now staff Cardiologist at McGill) Dr. Hanane Benbarkat, we explored current and further applications of HHU and POCUS, all centred on its fundamental impact on patient care.
Dr. Johri has been active in the development of guidelines for its application in medical education (Journal of the American Society of Echocardiography 2018;31:749), and has been working with Dr. Steven Pang of our department of Biomedical and Molecular Science to introduce the technology within our curriculum.
The session was, as you might imagine, not without controversy. However, I believe the discussion ultimately centred on the only truly relevant issue: how we can utilize emerging technology to better serve the needs of patients. The concluding messages I provided our audience at that symposium are:
- HHU and POCUS are excellent examples of disruptive innovation
- They challenge our conventional approaches, but have considerable potential to bring added value to both the clinical setting and educational process
- They are here to stay – but how, and who will be guiding their use is not yet determined
- They have the potential to evolve from disruptive to sustaining innovations
- The key consideration in assessing value should be the impact on patient care
- Based on work carried out by Dr. Benbarkat during her fellowship at KHSC and hopefully extended to further collaborative studies with other centres, integrated utilization of POCUS by hospital-based Echo Labs is feasible and beneficial.
I’ll conclude with the words of Mr. Christensen who has given much thought to what causes organizations to fail in the face of disruptive innovation. In his book “The Innovator’s Dilemma” he provides a rather disturbing paradox:
“in the case of well managed firms…good management was the most powerful reason they failed to stay atop their industries.”
“widely accepted principles of good management are, in fact, only situationally appropriate.”
In other words, it was, at least in part, a failure to deviate from previously successful practices that prevented well-established firms from engaging disruptive innovations, ultimately to their detriment. Such innovations challenge us to step away from what we consider to be the “tried and true” methods and approaches we have come to rely upon. They will always entail an element of risk and uncertainty, and therefore require what might be termed a leap of faith. In the medical world, that leap is only justified by a considered, clear potential to improve patient outcome. All other considerations must take a back seat.