Can admissions committees measure adversity? Should they?

“If you can’t measure it, it doesn’t exist.”

This was the mantra of a former mentor and research supervisor with whom I had the opportunity to work during my fellowship. In the early days of Echocardiography we, and many others, were working hard to bring some degree of quantitative rigour and credibility to a developing imaging modality which, at that time, consisted of rather blurry black and white recordings of the beating heart on a small screen. The images could be photographed and even videotaped. As such, they were remarkably informative to the person obtaining the image and treating the patient under observation, but the technology provided no inherent measurements and could not be transmitted to referring physicians. If Echocardiography was to have sustaining value as a service to the larger medical community, most contended, it must yield measurements that would differentiate normal structure and function from the pathologic. Hence countless postulates, projects, manuscripts, publications and fellowships, including mine.

In most cases these efforts to derive measurements and “normal ranges” from moving images have been of great clinical value and has advanced patient care. However there have been, and continue to be, numerous instances where over-zealous attempts to quantitate have caused misinterpretation, often due to over-simplification of a complex image or set of images that has much more value to the observer than any static measurement can convey. Trying to compress the meaning of an image into a set of simple measures will always have inherent limitations. What numeric value could one apply to da Vinci’s Mona Lisa that would convey even a fraction of what the human eye and mind can perceive in a few seconds of observation?

Recently, considerable controversy has arisen in the United States as a result of attempts to incorporate measurements of adversity into the college admission process. The Scholastic Aptitude Test (SAT) is undertaken by American high school graduates and is a key component of their application to colleges and universities. It is widely considered to be a primary driver of admission decisions in an environment where admission to “top tier” universities is highly competitive and, recently, the subject of criminal prosecution in the United States.  

This new score, dubbed the “Adversity Index” is a composite of 15 factors, including measures of crime rate and poverty in the neighbourhood in which the applicant has been raised and an assessment of the “quality” of the high school attended.

https://www.wsj.com/articles/sat-to-give-students-adversity-score-to-capture-social-and-economic-background-11557999000

It provides a score scaled between 1 and 100, with higher scores indicating greater degrees of “disadvantage”. The Adversity Index is not used to adjust SAT test scores in any way, but provided separately to admission committees, presumably to “contextualize” the scores as they see fit.

The intent appears to be to level the admissions playing field that most agree favours applicants from wealthier backgrounds who can attend more academically rigourous high schools and benefit from more time and support for academics. It is also felt to identify students who have overcome personal adversity and demonstrated commitment and resourcefulness in order to achieve their success. The New York Times article cited above quotes Mr. David Coleman, CEO of the College Board:

“Merit is all about resourcefulness. This is about finding young people who do a great deal with what they’ve been given. It helps colleges see students who may not have scored as high, but when you look at the environment that they have emerged from, it is amazing.”

As one might imagine, not all agree. American College Testing (ACT) provides an alternative admission test for college applicants. Its CEO, Mr. Marten Roorda states the counter-argument in a recent blog post:

 “The algorithm and research behind this adversity score have not been published. It is basically a black box. Any composite score and any measurement in general requires transparency; students, teachers and admissions officers have the right to know. Now we can’t review the validity and the fairness of the score. And even if that changes, there is also an issue with the reliability of the measure, since many of the 15 variables come from an unchecked source — for example, when they are self-reported by the student.”

http://leadershipblog.act.org/2019/05/adversity-score-college-boards.html

All this comes about at a time when college and university admission processes are under siege as a result of a number of highly publicized reports of inappropriate influence exerted by wealthy and influential parents.

https://www.cbsnews.com/news/college-admissions-scandal-bribery-cheating-today-felicity-huffman-arrested-fbi-2019-03-12/
https://www.nytimes.com/news-event/college-admissions-scandal

The repercussions and resulting enquiries have uncovered dubious practices, even in venerable institutions.




https://www.nytimes.com/2018/10/19/us/harvard-admissions-affirmative-action.html?module=inline

And so, what are we to make of all this? Does any of this translate to Canada, and specifically to medical school admission, certainly among the most competitive choices available to young people? A few key questions and postulated answers. (Please note: following are the opinions of the author, and the author alone).

Q. Does wealth and privilege facilitate admission?

A. Almost certainly yes. For further discussion see previous blogs:

Does every Canadian have equal opportunity to pursue a Medical Education?

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=1165&action=edit

Medical School Admissions: Unintended Consequences

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=407&action=edit

Medical Student Debt: A problem, or shrewd investment?

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=1807&action=edit

Q. Do we wish to admit a more diverse student population, including students from traditionally socioeconomically disadvantaged groups?

A. Yes. All medical schools have engaged this challenge in various ways. At Queen’s both the medical school and university have made clear statements to this effect.

https://www.queensu.ca/universityrelations/equity
https://meds.queensu.ca/academics/undergraduate/policies-committees/diversity-equity-statement

Q. Do adversity experiences build qualities desirable in medical school applicants?

A. They may, but not necessarily. Simply experiencing adversity is not sufficient. That experience must have resulted in a valuable learning experience that has contributed to the applicants ability to choose and undertake a career in medicine. In fact we must recognize that adversity experiences, unfortunately, have the potential to be highly damaging.

Q. How does “disadvantage” equate to “adversity”.

A. They correlate, but not precisely. To use an example from the cardiology world, sedate hypercholesterolemic people are at higher risk of developing premature ischemic heart disease, but they may not, and many active folks with normal cholesterol levels will. This is the nature of a “risk factor”. Lower socioeconomic status certainly puts one at risk for greater life adversity, probably at a linear fashion where poverty levels virtually guarantees adversity. Conversely, socioeconomic stability certainly provides no immunity from adversity experiences.   

Q. Will an Adversity Index developed from compiled demographic and self-reported data provide a valid reflection of a student’s development and preparation for a career in medicine?

A. In and of itself, probably not. The information upon which it is based is inherently flawed, imprecise, and subject to manipulation.

Q. Will an examination of personal adversity and its impact on personal growth be helpful?

A. Yes. The study and practice of medicine requires commitment and resilience, both of which can be developed by adversity experiences successfully engaged.

And so, examining disadvantage is essential to addressing diversity goals, but Admissions Committees must develop robust methods to  determine if adversity has been experienced, and what impact has resulted from those experiences. A numerical index such as that developed by SAT may provide a useful starting point, but is no more revealing than is a linear dimension obtained from recordings of the beating human heart.

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Spring UGME retreat May 28

The spring UG Education retreat is coming up on May 28 at the Donald Gordon Conference Centre.

Designed primarily for course directors, unit leads, intrinsic role leads and others in educational leadership roles in our Undergraduate Medical Education program, this annual day-long event provides opportunities for information sharing and faculty development in planning for the next academic year.

The morning agenda includes an update from Associate Dean Anthony Sanfilippo as well as sessions on the progress test and quality assurance, accreditation & program evaluation. There will also be brief updates from the Librarian team at Bracken Library about new resources, and from the course team about the Human Structure & Function curriculum renewal.

The afternoon will begin with our guest speaker, Melissa Forgie, MD, FRCPC, MSc, Vice dean, UGME, University of Ottawa. She will speak on Embracing Diversity in Medical Education

Break out sessions will follow, including a working session for pre-clerkship course directors to build or revise assessment plans for next year and a clerkship course directors’ session on continued EPA/CBME implementation.

If you contribute to the Queen’s UGME program, please join us for all or part of the day. To register, use this link:  https://queensfhs.wufoo.com/forms/ugme-may-28-retreat-registration/

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Climate Change: What is our role?

By Sasha Létourneau with Gabe Lam and the Environmental Advocacy in Medicine group

“When the health effects of tobacco became known, the CMA quickly changed its investments. In times of climate change, health organizations around the world are divesting in fossil fuels.”  – Courtney Howard, Emergency Medicine physician and President of the Canadian Association of Physicians for the Environment

We (Canadians) are addicted to fossil fuels. There. I said it. Isn’t admitting it supposed to be the first step? Much like a smoker with a 20 pack-year history, humans stand on the brink of irreversible damage to that which sustains us, having to make the choice as to whether to quit or continue down a destructive path.

When I first started medical school, I took a history from a man who had been diagnosed with lung cancer after a 50 pack-year history of smoking. I was quite astonished when he admitted he had been shocked by the diagnosis. How is that possible? I thought, thinking back on all the anti-smoking ads I’d grown up with in school, and the terrifying pictures of black lungs and rotted teeth I’d seen on cigarette packages strewn on the sidewalk. How did he somehow ignore all the signs around him? These are questions I hope my children never have to ask my generation about climate change.

Continuing down the fossil fuel-burning track we are on today is easy in that the ramifications of our actions are not yet apparent in most of our everyday lives. Despite the fact that CO2 levels have risen far beyond where they have ever been in the past 400,000 years,1 we are only just starting to experience the effects of climate change. And much like COPD or lung cancer, the threats of climate change most likely to impact Canadians seem just far enough away that they are still only a hazy blur. Yet, like a smoker who is only just starting to experience the first signs of shortness of breath, we too have reached a tipping point and we need to act as soon as possible.

Studies have shown that among the top most important reasons Canadians begin the extremely difficult process of smoking cessation is their concern for their personal health.2,3 If health care professionals so adamantly advocate for smoking cessation to prevent our patients from its long-term health consequences, should we not, for the same reason, also advocate for cessation of fossil fuel dependency? And how do we convince a society (and, quite frankly ourselves) that this issue needs to be addressed now?

We’ve seen a number of recent examples that climate change is starting to threaten human health, including climate-related natural disasters like cyclone Idai which claimed hundreds of lives in Mozambique in March 2019. Touching a bit closer to home, the extreme temperatures of the Quebec heat wave in the summer of 2018 took the lives of more than 90 Canadians. And even closer to Kingston, many of us have watched with horror the footage of the recent flooding in the Ottawa River that has displaced hundreds of Canadians from their homes. I, personally, might even decry the number of lectures Queen’s Medicine students endure on Lyme disease as a direct result of climate change facilitating the spread of this tick-borne infectious disease.4

But most of us fossil-fuel “addicts” are already convinced that we need to begin to transition away from our weighty reliance on fossil fuels. So now comes the hardest part – beginning the process of actually quitting. The Intergovernmental Panel on Climate Change (IPCC) released a report in 2018 telling us that, in order to ensure global temperatures remain below 1.5˚C above pre-industrial levels, we need to significantly curb our fossil fuel use by the year 2030 and achieve net-zero carbon emissions by 2050. Why is this 1.5˚C cap so important? While 1.5˚C is still higher than current temperatures, keeping global temperatures at or below this level is humans’ best chance of mitigating further catastrophic events, including land loss from rising ocean levels, extreme heat waves, drought, increased ocean acidity and both land and ocean biodiversity loss. These climate events will inevitably threaten human health, food security, water security, job security, economic growth and physical safety from war and climate disasters.5

Unfortunately, (as far as I know) there is no magical solution and no promise that this transition will be immediate or smooth. And, like a smoker trying to quit, it is probably not realistic for us to quit cold turkey – we still are years away from being in any way independent of fossil fuels. We also need to ensure we enact a just transition for our fellow Canadians currently working in the fossil fuels industry. But if we never start the transition, if we never grasp hold of the “greatest global health opportunity of the 21st century” – tackling climate change – we will never know if we could have succeeded.6

If you’ve reached this point in the article, you may be wondering: what can I, a lowly Queen’s student/faculty/alumnus, contribute to the struggle against climate change? What can one single Canadian do? Luckily, the answer is: a lot! In this article, I’ll present you with a few ways you can start to engage as a climate advocate.

One avenue that our medical student group, Environmental Advocacy in Medicine, has undertaken is working with the Queen’s Backing Action on Climate Change (QBACC) group to ask that Queen’s divest from fossil fuel companies. We are joining them to ask that Queen’s:

  1. Freeze fossil fuel investment immediately
  2. Fully divest the Queen’s Endowment and Investment funds by 2025

QBACC needs support from students, faculty and alumni. A mass divestment movement can stigmatize and delegitimize fossil fuel use and the profiting corporations in the court of public opinion, a strategy that has also been crucial in combating smoking culture and destabilizing tobacco companies. The list of organizations calling for divestment is long and growing with new players being added every day, including commitments from the Canadian Medical Association, McGill University, Oxford University, the RockFeller Brothers Fund, the British Medical Association, New York City’s pension fund, the country of Ireland and many more. This movement on Queen’s campus has been growing since the first formal request for divestment of Queen’s funds from fossil fuels was rejected by the Board of Trustees in 2014. A diverse basis of support that includes a broad community of current and future health professionals will be imperative when QBACC approaches the Board of Trustees at their annual meeting in 2020.

If this cause speaks to you, ways you can support it are:

1. Becoming informed about divestment by reading a bit more about their campaign here: https://drive.google.com/drive/folders/17PDgVGUXaLyefEp_IwzD4JZ2OANh0qsh?usp=sharing

2. Signing and/or personalizing a letter to the Board of Trustees stating your support of the divestment campaign at Queen’s University (here: https://drive.google.com/open?id=1wDYfBT5h005XyudA-ac32fSIEU_Y6QUc)

3. Signing QBACC’s support forms:

If that’s not enough for you or you are still not sure about divestment, here are some other ways you can choose a cause, join an advocacy group and work to have your voice heard:

1. Become informed about climate change by:

  • signing up for the Canadian Association of Physicians for the Environment newsletter here, or
  • reading CAPE’s Climate Change Toolkit for Health Professionals here.

2. Or, better yet, join CAPE’s team (if you are a physician) here.

3. Support the Queen’s Environmental Advocacy in Medicine effort to increase climate change education in the curriculum by including information on climate change in your teaching material (contact us for more information at: queensenvironmed@gmail.com)

4. Talk to your fellow students and colleagues about their thoughts on climate change!

We are that patient with the 20-pack-year history leaving the doctor’s office, having been told the risks of letting the status quo take its course. We stand at the edge of a frightening precipice in human history, where our actions (or inaction) today will determine the world our children and grandchildren get to live in. But like that patient, we are fortunate.  We know the importance of taking action and we have a timeline during which to do so. It is now up to us whether we seize the “greatest global health opportunity of the 21st century.”6

References:

1. NASA. (2019, May 3). Graphic: The Relentless Rise Of Carbon Dioxide. Climate Change: Vital Signs Of the Planet. Retrieved from: https://climate.nasa.gov/climate_resources/24/graphic-the-relentless-rise-of-carbon-dioxide/

2. Wellman, R. J., O’Loughlin, J., O’Loughlin, E. K., Dugas, E. N., Montreuil, A., & Dutczak, H. (2018). Reasons for quitting smoking in young adult cigarette smokers. Addictive Behaviors, 77, 28-33. doi:10.1016/j.addbeh.2017.09.010

3. Kasza, K. A., Hyland, A. J., Borland, R., McNeill, A., Fong, G. T., Carpenter, M. J., . . . Cummings, K. M. (2017). Cross-country comparison of smokers’ reasons for thinking about quitting over time: Findings from the international tobacco control four country survey (ITC-4C), 2002–2015. Tobacco Control, 26(6), 641-648. doi:10.1136/tobaccocontrol-2016-053299

4. Brownstein, J. S., Holford, T. R., & Fish, D. (2005). Effect of Climate Change on Lyme Disease Risk in North America. EcoHealth2(1), 38–46. doi:10.1007/s10393-004-0139-x

5. https://www.ipcc.ch/sr15/

6. Watts, N., MA, Adger, W. N., Prof, Agnolucci, P., PhD, Blackstock, J., PhD, Byass, P., Prof, Cai, W., PhD, . . . Stockholm Resilience Centre. (2015). Health and climate change: Policy responses to protect public health.Lancet, the, 386(10006), 1861-1914. doi:10.1016/S0140-6736(15)60854-6

Links:

1. Link to “Investing in a Sustainable Future” document prepared by QBACC: https://drive.google.com/drive/folders/17PDgVGUXaLyefEp_IwzD4JZ2OANh0qsh?usp=sharing

2. Link to letter of support faculty/alumni can edit and send to QBACC: https://drive.google.com/open?id=1wDYfBT5h005XyudA-ac32fSIEU_Y6QUc

3. QBACC faculty support form: https://www.qbacc.org/divestment-petition

4. QBACC alumni support form: https://docs.google.com/forms/d/1onGYQBJAiDpPK0r7TbLqf1V0lj_sAWSCEYS_TkQdeMI/viewform?edit_requested=true

5. Sign-up for CAPE newsletter: https://cape.ca/media/blog/

6. Link to Climate Change Toolkit for Health Professionals: https://cape.ca/campaigns/climate-health-policy/climate-change-toolkit-for-health-professionals/

7. Sign-up for CAPE membership: https://cape.ca/become-a-member/

If you are a Queen’s UGME student who would like to submit a column for consideration as a guest blog, email me at theresa.suart@queensu.ca

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“We’re all Chinese”. The freedom to express our diversity…or not.

I recently had the opportunity to visit a Chinese medical school and spend some time with both faculty and students. The leadership of the school was interested in pursuing North American accreditation. I was part of a team invited to advise about the state of compliance with those standards, and to help prepare the faculty and curricular leadership for the review process.

The visit was organized in the style of a typical accreditation visit, structured as a series of interviews with groups of faculty, curricular leaders, students and administrative staff. Each meeting was typically focused on a subset of standards.

One such meeting, which I’d been dreading, involved the accreditation standards dealing with the issue of Diversity. I was not at all sure how the North American sensibility regarding diversity would translate to such a different cultural and political setting, and was concerned about inadvertently causing some offense to our hosts, who had been nothing but gracious.

The meeting involved about ten faculty and administrative staff. They were chosen, in part, because of facility in English, but their understanding and ability to express responses varied considerably. As a result, questions were often followed by spontaneous conversations in Mandarin where those with better understanding would translate to others and, presumably, responses were considered and formulated. These “huddles” sometimes got quite animated and the tone and gestures themselves seemed very revealing.

The preliminary questions for this particular session were quite straightforward, generally confirmation of factual information. All was going along quite smoothly with a generally light and friendly atmosphere in the room. Then, and in the interest of simulating a true accreditation visit, I probed further. “And how do your admission practices and curriculum recognize the diversity of your population?”

The previously relaxed and animated group went quiet, all eyes on me. After what seemed like a very long pause, the faculty member who’d been the lead discussant for the group asked me to clarify what I meant by “diversity”.

I tried to explain that North American medical school standards required a commitment to social accountability, a component of which was the recognition of cultural, gender and ethnic differences in the students and society they would eventually serve.

My explanation was translated to the group, followed by the most animated and prolonged exchange they’d had to date. The other panel members and I sat back taking all this in. The expressions and tone suggested confusion, perhaps mild offense and considerable concern about how to respond.

After what seemed like quite a long and somewhat uncomfortable time, the lead faculty member turned to me and said simply, “We’re all Chinese”

With more than a little trepidation, I decided to press on. “But I’ve read recently that there are over 50 different ethnic and cultural groups within China. Diversity also extends to issues of gender and sexual orientation. How is that diversity accounted for in your admissions and faculty appointment processes, for example?”

After another translation, an even longer and more animated Mandarin huddle ensued. Finally, the response:

“But, we’re all Chinese”.

In the interests of maintaining good relations and ensuring the review team got home safely, I decided to leave it at that.

In the ensuing months, my thoughts have often returned to that particular exchange. Of all the conversations during that visit, that was the one that brought home most clearly the differences in our societies. Fundamentally, the Chinese political structure and the values that it espouses prioritize the state over the individual. It’s not that myriad cultural, racial, religious and language differences don’t exist or are unimportant to their 1.5 billion citizens, it’s simply that those differences are considered secondary to their common, unifying allegiance to the state. They’re all Chinese first. Other characteristics, choices or preferences come second, or not at all. They have, as a society, essentially chosen to suppress or ignore their diversity.

All this is in rather stark contrast to our culture in Canada where diversity is celebrated and even legislated, permeating even our educational programs. We are free, as Canadians, to identify in (almost) any way and with (almost) any group we chose, the exceptions being organizations that are known to advocate violence or hatred in the pursuit of their particular perceptions of diversity.

I came away from all this with a deeper appreciation of the incredible privilege our society provides. The freedom to choose how one wishes to be identified is precious. It’s also easily taken for granted, largely because most of us have never had to struggle to achieve it, and have never lived without it.

What my brief and admittedly superficial encounter with Chinese culture brought home to me is that we all have the freedom to choose how we wish to engage each other, and how we collectively wish to engage the world. For any two people, indeed for any two peoples, both common and differentiating issues can be easily identified. In any encounter, from simple to profound, the parties involved face a choice. Their encounter and their ongoing relationship can be defined by points of mutual interest, or by those characteristics that divide them.  

All this brings to mind the words of President John F. Kennedy who, in a commencement address at American University in 1963, at the height of the Cold War, nuclear proliferation and the constant threat of accidental or intentional Armageddon, reached out to both his own people and his global adversaries with these words:

“So let us not be blind to our differences, but let us also direct attention to our common interests and the means by which those differences can be resolved. And if we cannot end now our differences, at least we can help make the world safe for diversity. For in the final analysis, our most basic common link, is that we all inhabit this small planet, we all breathe the same air, we all cherish our children’s futures, and we are all mortal.”

How will we, as Canadians, chose to use the freedom of choice that we have inherited? From time to time, might our chosen approach to our various diversity challenges be “We’re all Canadian”?

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