Case Reports Database

Dr. Kanji Nakatsu shared this resource with us recently.  It’s a bank of Case Reports, from Biomed Central and supplemented by the Journal of Medical Case Reports.  It is searchable and freely accessible.  This is a resource for physicians, but may also be used in medical education.  “By bringing similar case reports together, through the Cases Database, researchers and clinicians can start to look for new knowledge – new associations, new side effects, new thoughts about disease processes, new understandings about the impact of disease on our patients and our communities.”

Access it by going to

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Revised Policy: Student Initiated Extracurricular Learning Activities

The Teaching and Learning Committee is requesting comments on revisions made to the  policy on Student Initiated Extracurricular Learning Activities.  A summary of the changes are listed below. The full revised policy may be viewed by clicking here.   Please submit all comments no later than March 8, 2013 by using the “Discussion” Comments: Policy on Student Initiated Extracurricular Activities

Student Initiated Extracurricular Learning Activities have been in place for many years.  A policy is needed only to ensure that these activities complement but do not supersede planned curricular activities and to direct those activities that become part of the “Dean’s Letter”. The last version of this policy, 2007, has received only a few changes:

  • A new definition and background statement have been added specifying that these activities must not impinge on curricular time.
  • The new Student Liaison position in the Aesculapian Society which offers substantial assistance to students, UGME Office and Teaching and Learning Committee, has been woven into the procedures.
  • The procedures have been separated from the policy.
  • The Teaching and Learning Committee now assumes responsibility for vetting and approving these activities as part of their mandate to oversee opportunities for independent and lifelong learning.
  • The students’ submission of attendance records only will trigger the entry into Dean’s Letter.

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Medical School Admissions: Striving for fairness despite “ill-designed” tools

February is, easily, the most difficult month of the year for many involved in undergraduate medical education, including Deans, admissions committees and administrative staff.  This is not simply because of the long and dreary Canadian winter.  It’s during this month that letters go out to applicants for admission indicating whether they’ve advanced to the next stage of the process: the on-site interview.  All those involved in the selection process struggle with the knowledge that, for every letter that brings welcome relief and encouragement, several will result in bewildered disappointment.  Two brief applicant profiles may serve to illustrate the issue.

Jessica is a bright, articulate and engaging young woman who, for as long as she or anyone can remember, has wanted to be a Doctor.  She graduated from high school at the top of her class, with numerous awards recognizing not only her academic accomplishments, but also student leadership and community involvement.  She received multiple university entrance scholarships and undertook an undergraduate program with courses that would provide a basis in biologic and physical science, which she feels is relevant to the study of medicine, but also selected to optimize her marks.  She is very successful, maintaining a 3.8 GPA over her first three years.  She also undertook a variety of volunteer activities, locally and abroad, involving health care in various settings.  She took the Medical College Admission Test (MCAT) after both studying from a manual and taking a preparation course at significant expense.  She did generally well, but was concerned about her mark in one of the four exam categories.  Jessica applied to our medical school, but failed to even get an interview.  This was related entirely to the MCAT score, as she feared.

Matt is not only an excellent student finishing in the top 5% of his high school graduating class, but also an elite athlete who accepts a full scholarship to an Ivy League university.  He chooses this school because it will allow him to pursue his interests in philosophy and political studies at an institution with an international reputation for excellence in both disciplines.  While there, he continues to excel academically, while becoming an accomplished varsity athlete.  He also develops an interest in Medicine and, specifically, Public Health.  He decides to apply to medical school and takes the MCAT, in which he excels in all categories.  He would like to return to Canada for medical school, but also fails to even get an offer for an interview, largely because the grades for his philosophy and political science courses, although near the top of the class for every course, fall below our GPA cutoffs.

Jessica, Matt, their families, and everyone who knows them and their career aspirations, are understandably devastated and rather perplexed.  “How can this be?”

Although these are both fictional accounts, a recent review of our applications at Queen’s shows that no fewer than 247 submissions matched the “Jessica” scenario almost exactly.  The number of “Matts” is more difficult to determine, but likely similar and probably underestimated because many people in such circumstances will decline to even apply, recognizing the GPA issue.

For every jubilant success, we know there are about 7 “Jessicas” and “Matts” who will be very disappointed and may have to set aside or delay their life’s dream, despite being very capable, motivated and deserving.  That reality is also personally distressing to the faculty and staff involved in the admissions process who, recognizing they cannot admit every applicant, endeavor diligently to develop fair and equitable processes.

A few realities about the medical admission process in Canada:

Among Canadians, there is a very high demand for medical education.  At Queen’s we received 3818 applications for our 100 positions this past year. All Canadian schools receive many times more applications than they can accommodate. Statistics collected and published annually by the Association of Faculties of Medicine of Canada indicate that the Canadian schools collectively received 34,048 applications for their 2,877 total available positions in 2011.  Assuming an application per candidate ratio of 3.3 (as Ontario statistics would suggest), it would appear that at least 10,318 individuals submitted applications that year.  The hunger for a career in medicine is such that increasing numbers of Canadians are enrolling in medical schools in Australia, the Caribbean, Ireland and other countries, at considerable personal expense and with no assurance of postgraduate training or eventual qualification in Canada.  Although no accurate data is available, it’s estimated that there are now more Canadians studying Medicine outside Canada than within.

Applicants to Canadian medical schools are knowledgeable regarding the process, and highly accomplished academically.  Although, again, no data is collected on this subject our observation at Queen’s, which seems to be shared by other schools, is that the average GPA, MCAT scores and personal experiences reported by our applicants are increasing each year.  Applicants understand the “system” and are highly strategic as they undertake their education and personal activities.

The number of medical school positions in Canada is fixed by public authority.  Medical education is expensive and largely subsidized by provincial governments.  Those governments therefore define the number of available positions, based loosely on anticipated demands for physicians.  These estimations have fluctuated in the past such that we have seen periods of both contraction and expansion.  At present, there are no plans in Ontario for expansion.

Medical schools place a priority on fairness and equity in their application processes.  In the face of the virtual impossibility of selecting the “most worthy” from so many worthy applicants, schools opt to ensure objectivity and fairness in their processes.  They are therefore drawn to metrics that provide some basis for objectivity.  Unfortunately, all available metrics are inherently blunt and imperfectly aligned with the qualities all would agree are important.

Winston Churchill could have been talking about medical admissions when he famously described golf as “a game whose aim is to hit a small ball into a small hole, with weapons singularly ill-designed for the purpose”.   Academic records, the MCAT, and quantified assessment of reported personal experiences all have significant shortcomings, as our examples above illustrate, but have the significant advantage of providing a numerical assessment by which candidates can be ranked without prejudice.  Panel interviews and mini-medical interviews (MMIs) are being used increasingly by medical schools to better assess applicants personal qualities, and are certainly an improvement, but are very resource-intensive and difficult to conduct and evaluate in a reliable manner.  It’s therefore not possible to apply such methods to the large number of applicants.  Hence the staged application process and reliance on other academic and test metrics.

So, one must ask, do we have a problem?  Despite all these shortcomings, the students who are finally admitted to our medical schools are an exceptional group of very talented, intelligent and capable young people who, with rare exceptions, have all the necessary qualities to become outstanding physicians.  Our processes, although inherently blunt and likely misaligned, are objective and scrupulously fair to all applicants.  Importantly, the Jessicas and Matts of the world, and their families, can perhaps take some small comfort in the knowledge that they are far from alone and have been treated fairly.  Furthermore, medical schools recognize that even if they could personally interview or meticulously assess every applicant, most would still be disappointed.  So, should we change and, if so, how?  I welcome viewpoints, and will make that issue the subject of the next blog.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

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Updated Faculty Resources Community Available

briefcaseThe newly-updated Faculty Resources Community is now available in MEdTech Central. This online resource contains great teaching and assessment ideas, highlights of Curriculum Committee, notes and slides from the retreats, and more.

The resource material available includes refresher instructions on the audio-visual equipment in teaching theatres 132 and 032 (including a map of the numbered student microphones), e-learning resources and links to the small group learning community.

This Faculty Resource Community is open to all faculty at the School of Medicine.  For more information, please contact Sheila Pinchin (sheila.pinchin@queensu.ca) or Theresa Suart (theresa.suart@queensu.ca).

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Family Medicine and the Hidden Curriculum

Lessons from Medical Variety Night

Last November’s Medical Variety Night provided an impressive peek into the musical and comedic talents of our students.  Andrea Winthrop, Steve Archer and I were asked to serve as a “Judges Panel” to determine the best class skit.  We were all amazed at the poise and creativity on display.

The evening also provided a few lessons for both faculty and students as to how well intentioned humour and satire can appear quite different before a mixed audience not familiar with the contexts employed.  A number of conversations have ensued which I believe have been illuminating and instructive for both students and faculty.  As in the patient care context, “near misses” are opportunities to learn and avert more serious problems in the future, and I believe we have, as a school, availed ourselves of the opportunities this year’s production provided.

A theme that I and others in attendance found particularly troubling related to a number of references to Family Medicine as a less-than-appealing career option.  This perception is hard to fathom given that we a have superb and award winning faculty teaching Family Medicine.  Our Family Medicine training program is widely recognized as one of the best and most sought after programs in the country.  In addition, Family Medicine is, arguably, the most demanding of specialties.  In open and frank discussions with a number of students on this issue, a few underlying causes came to light which I found illuminating and felt would be useful to share with faculty.  They provide superb examples of the “Hidden Curriculum”, a term used to describe unintended influences that affect student learning, and are known to be very powerful shapers of student attitude and behavior.  So, in no particular order:

  1. Engaging Uncertainty.  Students find Family Physicians they encounter to more commonly express uncertainly in their ability to resolve patient presentations.  This is in contrast to other specialists who they find characteristically more definitive in their approach.  Family Physicians more commonly use statements like “we’ll have to look it up”, or “don’t be afraid to say you don’t know”.   With respect to other specialists, the expression “seldom wrong but never uncertain” comes to mind (my quote, not theirs).  Importantly, students do not see this difference as inappropriate or as reflecting any lack of competence, nor are they so naive as to believe other specialists always have the answer.  In fact, the students I met uniformly expressed admiration and respect for Family Physicians they encountered, and their ability to manage a diversity of patient populations and presentations.  However, it’s clear that our students are accustomed to success, and many are not yet comfortable facing uncertainty in their lives, or in their future practices.
  2. Technical/procedural expertise.  Many of our students are technically very savvy and excited by the prospect of being on the “leading edge” of innovation and application of emerging technologies and procedural approaches to various conditions.  Simply stated, they like the “toys” of modern medicine and they’re excited about applying evolving procedures.  They perceive that these exciting new approaches as the exclusive domain of sub-specialists.
  3. Prestige”.  Hospital in-patient services remain at the core of clinical training for our students.  Properly run and supervised, they are superb environments in which the learning of pre-clerkship can be applied to real patients, with appropriate overlays of scholarship, professionalism, advocacy, collaboration and all the intrinsic competencies we have adopted within our curriculum.  Although formal teaching remains valuable during these rotations, we all recognize that the major component of learning occurs through active participation as part of the team, and by observation of “real life medicine”.  With respect to Family Medicine, these rotations are problematic in two important ways.  Firstly, virtually no Family Physicians are involved or even visible during these rotations.  Secondly, and most disturbingly, they often see instances where primary care and primary care providers are disparaged.  A casual reference suggesting that a patient was inadequately cared for prior to admission, or a concern that appropriate care will not be continued after discharge can, in a stroke, undo all prior teaching.  These observations in the clinical setting trump teaching in the pre-clerkship.  Our actions, it would seem, speak more loudly than our words.
  4. Money.  I have become convinced that the single most powerful expression of Hidden Curriculum in our society is the OHIP Fee Schedule.  Students are very aware of the differential reimbursement of physician groups, and the high premium paid for procedural work relative to patient assessments.  This of course, results in two hugely damaging consequences, the equation of financial with professional “value” or “prestige”, and the enticing allure of higher income to students facing increasing debt loads by graduation.

So what can be done?  A few suggestions, humbly submitted for consideration:

  1. Awareness of these influences, and of the Hidden Curriculum in general.  Hopefully this article is a start.  I hope it will generate some discussion, particularly at department meetings.  Dr. Leslie Flynn is chairing a group of which I’m a member to study and address Hidden Curriculum issues, and I think this may provide some focus for those discussions.  This awareness must extend to physicians of all disciplines who teach and supervise our students, particularly in the practice setting.  Those who attend on these services are, in my experience, largely unaware of the serious impact of casual commentary, and almost never intend to disparage any other specialty.
  2. Within our curriculum, developing strategies to address the “uncertainty principle” in a more open fashion.  This is both an academic and student wellness issue.  Our students require means to cope with the uncertainty that will inevitably develop in their professional and personal lives.
  3. Serious consideration of the troubling question:  To what extent do our admission processes pre-determine career choice?  Medical school admission remains a highly competitive process (applicant to admission ratio 38:1 at our school), and is likely to become even more competitive in the near future.  This environment favours the goal oriented, determined self-starter who is able to engage this single goal with appropriate compromises and sacrifices along the way.  It can be argued that such “survivors” will be naturally attracted to practice environments that provide definitive resolution of problems, technical mastery and perceived prestige.  There is a recognition, even embedded in the Future of Medical Education in Canada initiative, that admission processes should favour resiliency, personal maturity and problem solving, qualities valuable to any physician and not necessarily reflected by academic success.  Our admissions committee has, in fact, been inoculating these considerations into their procedures for the past few years.  However, as for all schools, academic success remains a key component of the application process.  Perhaps it’s time to consider more radical approaches.
  4. Increasing Family Physician presence in the hospital.  Our students perceive that in-hospital care, and the acuity, complexity and technologic innovation that goes with it, is the exclusive domain of sub-specialists, and fail to appreciate the role of Family Physicians in the continuum of care.  They also get little exposure to the in-patient care provided by Family Physicians in smaller communities.  Our Integrated Clerkship and “Week in the Country” programs address this to some extent, but we need to develop and engage initiatives to integrate Family Physicians effectively into the care of our in-patients.
  5. Advice regarding financial planning and practice management.  Although we can’t influence the fee schedule, we can certainly provide our students with sound financial advice to lessen any economic drivers of career choice.

I would like to end this article by thanking the many students who were willing to speak to me candidly about this issue.  I welcome their further commentary and impressions of faculty.  Open discussion is always the first and perhaps most necessary step to improvement.

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Blogs our medical students are using to learn: by Eve Purdy (Meds 2015) and Sheila Pinchin

When you think of medical students learning about medicine, you might think about lectures, textbooks, labs, small group study and even online learning modules.  BUT, did you know that our students are also learning through blogs?

Blogs, or “web logs” consist of postings by a person in chronological order with the ability for others to respond.  You’re reading a blog right now.  Our students read them too for all kinds of reasons and to access all kinds of material.  See below for Eve Purdy’s picks and some reasons our students are blogging through medical school.  For a great video on social media (blogging, twitter, etc.) see the Harvard Panel on Social Media at https://www.youtube.com/watch?v=_OdaDJ2PLmQ

What are your thoughts on learning through blogs?

Why are our students learning through blogs?

Blogs are ENGAGING and allow for knowledge sharing, reflection and debate not simply dissemination of facts

Blogs break down traditional hierarchies in which a medical student might feel intimidated to challenge a resident or attending on a concept or idea. Blogs not only prevent students from feeling intimidated but they create an environment where all are equals

Many good blogs will have links to primary literature that can help answer practical questions that come up in clinic;  blogs written by learners often address the same questions other students ask and then point in the direction of some good background papers

Blogs help students see the same information in different ways.  They allow learners to find ways to engage in ways that are most meaningful to them. By seeking out their own resources students find they are able to remember and recall information because they were responsible for going through the method to get there.

Often, the colloquial and entertaining way blogs are written make reading them easy and actually quite fun (urinalysis voodoo: http://boringem.com/2012/12/12/urinalysis-voodoo/)

Blogs are often inspiring, remind learners and faculty why we are doing what we are doing

Students turn to blogs to address some needs that are not always met or to augment resources in the curriculum (ie learner wellness http://wellnessrounds.org)

People who write blogs generally aren’t getting much (or any) scholarly credit which means they are doing it because they WANT to. Bloggers take a great deal of pride in presenting information in new, helpful ways and once they find a target audience or niche are very good at what they do. They are quick to adapt to feedback and to incorporate/synthesize new information in ways that traditional outlets (journals and textbooks) cannot.

Examples of students learning through blogsEve Purdy’s gives us some picks:

– I’m in the ER and see a patient with something that might be atrial flutter but isn’t quite sure so I pull up this quick, easy to reference article on atrial flutter from “life in the fast lane” (one of the best blogs out there) http://lifeinthefastlane.com/ecg-library/atrial-flutter/ It gives a nice, simple review of information quickly without having to log in to my queensu/bracken library account (something that takes about 30 seconds- an amount of time that doesn’t seem like much written down but makes a big difference if you are referencing a bunch of things throughout the day)

-Learn the same topic through multiple lenses.  For example….a student is interested in learning more about a patient with chest pain.  If you prefer clinical cases check out (http://lifeinthefastlane.com/education/clinical-cases/) or you like videos like the Khan academy use (http://academiclifeinem.blogspot.ca/2013/01/patwari-academy-videos-low-risk-chest.html). There are many resources to turn to and the people who keep blogs generally like to teach so the format is student friendly.

-Students don’t just read blogs to learn about content. The advantages of reading blogs goes much deeper and serves to address much of the hidden curriculum, thoughts about careers, tips and tricks for medical school success, health policy and once in a great blog post while inspire us to be better medical students and doctors in ways that traditional resources cannot. I think this is probably the most common reason that students read blogs. There are a bunch of examples but a few are:

careers (http://wellnessrounds.org/choosing-your-specialty/ or http://boringem.com/2013/01/16/carms-game-time-the-interviews/)

tips and tricks (http://boringem.com/2013/01/02/top-10-ways-to-rock-em-clerkship/http://www.kevinmd.com/blog/2011/10/nurse-offers-medical-student-sage-advice.html)

social issues in medicine (http://emergencycarecanada.com/2013/01/14/non-urgent-patients-in-the-er-a-non-problem/)

just for fun (but really do more like address the hidden curriculum and remind us why we are here) http://www.medicalaxioms.com or http://doccartoon.blogspot.ca

 

 

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Using the IDEAL banks of questions for your assessments

Obtaining IDEAL Consortium Questions

Queen’s School of Medicine has joined the IDEAL Consortium, an international assessment item-sharing collaboration among Schools of Medicine. The Consortium has 27 member schools from 11 countries. Queen’s and UBC are currently the only Canadian members.

The IDEAL Restricted Question Bank contains over 20,625 assessment items including 17,109 MCQs, 539 short-answer questions and 461 OSCE stations.  Collectively, members contribute about 4,000 new questions to the restricted and non-restricted question banks annually.

Restricted Bank:  Please contact your Curricular Coordinator to request sets of restricted bank questions in your subject area or questions on particular topics. (Zdenka Ko for Year 1, Tara Hartman for Year 2, Jane Gordon for Clerkship Rotations and Candace Trott for “C” courses in clerkship.) Restricted bank questions need to be kept secure, so they can only be used on final examinations. A Word document containing the questions (as well as their answers and “item numbers”) will be couriered to you, or you can request that a secure MEdTech community be created for you to share restricted questions with other faculty members in your course.

To use restricted questions on final exams, simply provide your Curricular Coordinator with the item number of each question and the order in which you would like the questions to appear on the final exam. If you are sharing restricted questions via a secure MEdTech community, you can copy and paste your question selections into a Word document and upload it to the Curriculum Coordinator’s folder in the secure community. It is important that the IDEAL restricted bank questions not be emailed except in password-protected Word files. The restricted questions must not be viewed by students except during the writing of final exams.

You can specify edits to any of the IDEAL items – including OSCE stations. If you edit the items yourself, please highlight your edits so that your Curriculum Coordinator can transfer the edits to the local copy of the IDEAL bank.

The old LXR bank contained many duplicate and triplicate questions, so please let your Curriculum Coordinator know the origin of each exam question (IDEAL? LXR? Original? From a colleague?) We especially need to know, for copyright and item submission reasons, if any questions did not originate at Queen’s. Questions that did not originate at Queen’s will be marked, “Do not submit to IDEAL”, but can be stored in the local copy of the IDEAL bank and used on Queen’s exams.

Unrestricted Bank:  Unrestricted bank items can be used in online quizzes, in clicker sessions, on midterms etc. Students can have full access to all unrestricted bank questions. Currently the MEdTech team is creating an interface for the unrestricted bank so that faculty members will have full access to the questions. At present, requests for emailed sets of unrestricted bank question sets can be sent to Catherine Isaacs (isaacs@queensu.ca).

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Back to the Future: Our Early Entry to Medical School Program (QuARMS)

What’s True and What’s Not

The School of Medicine is currently in the process of accepting applications for a two year, entry level educational initiative which, if successfully completed, would lead to admission to the first year of the MD Program. This initiative, dubbed QuARMS (Queen’s University Accelerated Route to Medical School) by governance committee co-chair Dr. Mike Kawaja, would be the only one of its kind in Canada. Students admitted to QuARMS in September 2013 would enter the MD Program, if successful, in September 2015, joining the class of Meds 2019.

Although it would be unique in Canada, this approach is certainly not novel. In fact, direct entry is the most common approach in many parts of the world, including Australia and most European nations. North American medical schools, including Queen’s, admitted students directly from high school until the early 1970’s. The factors that led to a shift to delayed entry included the increasing demand for medical school positions, the increasing emphasis on basic science preparation, and the demise of common examinations at the secondary school level.

This initiative, which has been under development for approximately two years, has attracted considerable attention across the country and has raised a number of questions among our student body. This led to a very well attended Town Hall recently during which Dr. Hugh MacDonald (QuARMS governance committee co-chair) and I answered a number of questions and accepted a number of very helpful insights. It was suggested that it would be appropriate to follow up that discussion with a newsletter to the entire student body to provide further clarification. I thought it might be best to structure this as a number of questions that seem to be arising repeatedly, and to make it available to faculty as well as students.

1) How many students will be admitted?

A maximum of ten students will be admitted each year. They will be part of the 100 ministry funded positions and not increase the overall class size.

2) How will they be selected?

The application process is linked with two scholarship programs, the Queen’s University Chancellor’s Scholarship and the Loran Scholarship. The Chancellor’s scholarship program invites every high school in Canada to nominate a student who has demonstrated a combination of academic accomplishment and community involvement. This is a well-established program. We are inviting students applying to that program to indicate interest in QuARMS. The Loran scholarship is a national level high profile scholarship which provides undergraduate funding for students who demonstrate a similar combination of academic accomplishment, social awareness and community involvement. These applicants will be similarly invited to apply to QuARMS. From these two sources, a group of 50 candidates will be invited to Queen’s for a series of interviews and encounters with faculty and students that will result in a ranking list that will be used to guide offers of admission.

3) What program will these students undertake?

These students will undertake a two year program with a combination of courses, seminar work and community projects. The intention is provide these students foundations in all of the component competencies that we recognize as essential to the practice of medicine and which are developed within the MD Program. This provides an opportunity to develop a premedical curriculum which is more relevant, integrated and linked to the MD Program. It also provides an opportunity for these students to learn in what we believe will be a more effective manner and one more consistent with the collaborative and lifelong learning that will required of them as physicians.

4) Is there an intention for this program to grow beyond these ten students and to replace our standard application process?

No. We recognize that it is the uncommon student who is sufficiently aware at the high school level to make a valid career decision regarding medicine. We do not wish to close off medical school to individuals who come to that decision later in life.

5) Who will oversee this program?

A governance committee has been established and co-chaired by Dr. Hugh MacDonald of the Department of Surgery and Dr. Michael Kawaja of the Department of Biomedical Science. Dr. Jennifer MacKenzie is in charge of the curriculum and is a member of the governing committee. Other members of the governing committee include the Associate Dean for Undergraduate Medical Education, three faculty members and two students.

6) Will all students in this program “automatically” enter medical school?

Students within this program will have to be academically successful and meet standards established by the governance committee. If they meet those standards they will enter the first year of the MD Program after two years. We anticipate that some students will either not achieve those standards or decide in the course of this program to undertake an alternative career.

7) Why are we doing this?

I feel there are a number of advantages to this initiative.

  1. A small number of students are aware and ready to undertake medical training early. We believe this provides them an opportunity to complete their training in a shorter period of time.
  2. This initiative addresses, to some extent, the socioeconomic disparities in admission to medical school in that it provides entry after a shorter period of time with less overall expense. We hope this will make medical education available to students who might not otherwise consider the option.
  3. It provides an opportunity to develop a premedical education that is more appropriate and aligned to medical school without the highly competitive and stressful environment that sometimes accompanies premedical education.
  4. It provides an opportunity to begin the development of core qualities and competencies essential to medical practice such as collaboration, communication and lifelong learning, qualities that are sometimes challenging to provide for students who have come through a traditional premedical education.

This is, and will remain, a controversial undertaking. It represents a significant break from convention and is somewhat uncharacteristic of a school that has tended to avoid controversy, and been described by some as being “on the leading edge of tradition”. In the final analysis, the leadership of our school and most faculty and students comprising it’s main decision making body felt that the potential of this rather bold and “back to the future” approach outweighed the risks and effort required. Appropriately, it was a characteristically medical “risk/benefit” analysis that carried the day. So, let’s buckle up, we’re in for an interesting ride.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

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What really drives learning?

Lessons from the famously self-taught.

Holidays are a great time to catch up on reading.  My own preferences are history and biographies.  This past couple of weeks, I’ve found it rather humbling to learn that some of the most influential thinkers and shapers of our society were essentially self-taught.  In fact, they seemed in some cases to thrive despite the benefits of traditional education or academic success.

Benjamin Franklin (1706-1790) led a peripatetic life, meandering through a variety of career interests, excelling in all.  He’s perhaps best remembered as, arguably, the most important and essential influence on the Continental Congress that would draft and ratify the American Declaration of Independence.  Along the way, he was a writer/journalist/publisher/politician/diplomat and, in his spare time, a scientist of considerable renown, receiving honorary degrees from both Harvard and Yale, and becoming the first person living outside Britain to receive the prestigious Copley Medal from London’s Royal Society.  Remarkably, all this was accomplished without the benefit of college or university level education.  In his excellent biography of Franklin, author Walter Isaacson describes three key educational components: the formative influence of his father who encouraged conversation and debate in the home, Franklin’s insatiable curiosity that spanned a huge variety of topics, and his access to books.  “Indeed”, Isaacson writes, “books were the most formative influence in his life, and he was fortunate to grow up in Boston, where libraries had been carefully nurtured”.  Despite this abundance, Franklin was required to actively seek out these books, generally housed in private libraries.  His apprenticeship in his brother’s print shop provided him opportunities to “sneak books from the apprentices who worked for the booksellers, as long as he returned the volumes clean”.

The facts regarding the education of Abraham Lincoln (1809-1865) are almost lost in the mythology that’s developed regarding his early life.  In Team of Rivals, author Doris Kearns Goodwin describes the challenges faced by the impoverished Lincoln as a “Herculean feat of self-creation”.  “Books”, she writes, “became his academy, his college. The printed word united his mind with the great minds of generations past”.  He also treasured conversation and stories he shared with interesting, informed people, and would analyze and reconstruct arguments afterward. He also undertook “solitary researches” in the study of geometry, astronomy, political economy, and philosophy.  “Life was to him a school, and he was always studying and mastering every subject which came upon him.”

Although Albert Einstein (1879-1955) did have the benefit of formal education, attending the Swiss Federal Polytechnic School, he was a mediocre, somewhat embittered student and was unable to secure a teaching position after graduation.  It seems he found formal curriculum far too rigid and stifling.  He eventually undertook relatively menial work at a patent office, which allowed him time alone to read and think.  It was during those years that he developed many of the theories that would revolutionize the field of physics and define his life’s work.  He also developed a social consciousness that, although less publicized than his scientific work, is in many ways equally intriguing.

So should these notable examples, drawn from three separate centuries, diminish our commitment to formal education?  Obviously not.  However, it would also be a disservice to simply dismiss them as prodigious intellects who managed to excel despite more primitive educational systems.  Simply put, it took more than brainpower for them to rise above their circumstances and become pre-eminent learners and, as a result, leaders of their times.  They also shared three essential qualities:

  1. Relentless curiosity and desire to understand.  Although the focus of that drive may have differed, the intensity and commitment were consistent.  They simply could not be deterred from learning.
  2. Willingness to apply themselves to their goal.  We tend to believe that people as gifted as Franklin, Lincoln and Einstein came by their success effortlessly, but this is far from the case.  Franklin was known by his contemporaries to habitually arrive at work earlier than anyone else and to work long into the night.  Lincoln often read or worked through the night, and photographs from the time document dramatically the physical toll.
  3. Commitment to betterment of their communities.  All three were motivated by a desire to improve their societies.  In fact, the energy and commitment that was so evident in their work appears to arise from this altruism rather than any personal self-interest.

It would seem that when these three qualities triangulate in an individual, great things are possible.  However, those possibilities are only realized if their environment provides a few necessary things, including access to information and people with whom they can converse, share and test ideas.

How does all this relate to our work as medical educators?  I think two important lessons emerge.  Firstly, it would seem that any admissions process would benefit by concentrating on means to identify within applicants the three essential attributes listed above.  Any student with these attributes is essentially programmed to succeed and will do so within, or in spite of, any educational system we choose to impose.  Put simply, the appropriately motivated, reasonably capable learner is essentially unstoppable.  Conversely, the absence of these attributes virtually dooms the process from the start, despite our best efforts.  Secondly, these examples would suggest that the learning environment we develop is at least as important as the methods we employ to deliver and assess knowledge.  Providing our learners with direction and opportunities to explore concepts and develop their personal learning skills is critical and, from the perspective of their ongoing career, much more durable than simply requiring them to reproduce pre-determined dollops of factual information.

All this should reassure us that the changes we’ve undertaken over the past few years with our admissions processes, curriculum, information technology, physical space, mentoring programs and educational methodologies are all positive developments, clearly moving in the right direction.  We should also be encouraged to creatively and boldly go further.

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Great Health Care Requires Great Medical Educators

Education is not an industrial process; it is a human one.

In the Dec. 10 edition of The Atlantic Monthly, Richard Gunderman, MD. PhD., examines different sets of components of excellence in medical education:  curriculum, instructional methods, and assessment techniques AND creativity, commitment, and inspiration of medical educators.  He focuses on the critical importance of fostering a generation of medical educators through support of medical education.  For the article see

http://www.theatlantic.com/health/archive/2012/12/great-health-care-requires-great-medical-educators/265906/

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