Wolves among the sheep

How does a nurse, working in public hospitals and nursing homes, manage to murder frail, elderly patients without detection?

How does it go on for 20 years, resulting in the deaths of eight patients under her care?

Why did it only come to attention and stop when the perpetrator herself confessed openly to the crimes?

These questions are the focus of an inquest commissioned to investigate the actions of Elizabeth Wettlaufer, a former nurse now serving a life sentence for the crimes to which she has confessed.

The inquest is scheduled to release its final report this summer, but documents recently released reveal a number of very sobering facts that should concern any health care professional and, particularly, those with leadership or administrative positions:

  • She was fired from her first nursing job in 1995 for stealing medications. However, following intervention by her nursing
    Dave Childes – Canadian Press

    professional association, the firing was noted officially as a voluntary resignation.

  • Between 2007 and 2014, while working at the Caressant Care centre in Woodstock, Ms. Wettlaufer was reprimanded no fewer than nine times for medical errors and general incompetence, refused recommendations to take leaves of absence and ignored threats from her colleagues that her increasingly suspicious behaviour would be reported to her licensing body.
  • She was finally fired in 2014. That firing was again officially noted as a voluntary resignation after her union intervened. As a result of that settlement, Ms. Wettlaufer actually received $2,000 and a letter of recommendation.
  • Between 2007 and 2014, while all these concerns were under review, she continued to kill residents of the Caressant Care centre by administering lethal doses of Insulin.
  • On two occasions, the coroner’s office was notified about deaths at chronic care facilities where Ms. Wettlaufer worked. No autopsies or investigations were ordered.

If Ms. Wettlaufer had not voluntarily confessed her crimes, they might never have come to attention. She has recently spoken out about loose regulatory processes governing the use of Insulin which made it possible for her to administer overdoses without detection.

This is, regrettably, not the first instance of a health care provider using a position of trust to facilitate murder.

Harold Frederick Shipman was an English physician, considered one of the most prolific serial killers of all time. In January of 2000 he was found guilty of killing 15 patients under his care and sentenced to life imprisonment, but a subsequent inquiry linked him to over 250 murders over his thirty year career. It seems that, in retrospect, numerous warnings of misbehaviour were ignored, including the fact that one of his first victims, an elderly lady previously in good health who was found dead only a few hours after a visit from Dr. Shipman, had recently changed her will to bequeath her entire fortune to him. In fact, most of his patients were in good health prior to visits with him during which injections were administered. It appears that at least three of the murders were directly witnessed by other personnel but nonetheless went unreported.

 

 

Joseph Michael Swango is an American who is currently serving three consecutive life sentences imposed in the year 2000 for the murder of patients who were under his care while he was practicing as a physician. It now appears he was responsible for as many as 60 fatal poisonings of both patients and colleagues. In retrospect, it is clear that there were signs of very troubling behaviour during medical school. Although considered intellectually brilliant, he exhibited a fascination with dying patients, to the extent of preferring to work as an ambulance attendant rather than going to his classes. It was found at one point that he had submitted falsified documents regarding completion of required tasks. Numerous fellow students and faculty raised concerns about his behaviour and honesty. He was nearly expelled but was allowed to stay on because one member of a review panel felt he should be given a chance to remediate. He was allowed to graduate one year after his entering class and, despite a very poor evaluation in his dean’s letter, secured a surgical internship. While on clinical rotations, nurses had reported multiple instances of apparently healthy patients dying mysteriously while he was on duty. On one occasion, he was caught injecting a substance into a patient who subsequently became very ill. Despite these warnings, no major sanction was imposed, although the program revoked its residency offer. He went on to work as a paramedic and laboratory technician. By changing his name and falsifying documents he was able to get into a variety of different residency programs at medical schools across the United States, and therefore work as a physician, all the time murdering both patients and co-workers, usually with injections of arsenic. The American Medical Association eventually did a thorough background check on one of his applications and uncovered the pattern of previous incidents. As a result, all 125 American medical schools and over 1,000 teaching hospitals were alerted to his identity and record. Effectively blacklisted from further residencies, he fled to Africa where he secured positions and continued to commit murder. A very complex and thorough investigation eventually led to his extradition, indictment and conviction.

These are, mercifully, very rare and extreme examples. However, they remind us that the intelligent sociopathic personality may find the medical or nursing professions ideal environments to prey on the innocent and satisfy the craving to kill. They also remind us that the patterns of deviant behaviour start early and without major impact until fully empowered. Set amongst trusting patients and innocent, often naive colleagues who would have difficulty even conceiving such behaviour, these monstrous individuals are like wolves among sheep. They may also benefit from the well-meaning protection of colleagues and supervising faculty whose first instinct will always be to help and cure rather than condemn. As in the case of Ms. Wettlaufer, they may also benefit from professional organizations and legal processes that put the interest of the individual above potential impact on current and future victims. Unless counterbalanced by administrations and leadership willing to undertake legal challenges and defend the broader interests of the public, profession, and future patients, these behaviours can go unchecked.

The upcoming inquest report will surely identify several points at which our processes failed to act and put an end Ms. Wettlaufer’s serial murders. However, there are lessons here for us all who are involved in medical education. The degrees and qualifications we bestow convey an assurance to licensing bodies, institutions and the public that the individuals who hold them are not only knowledgeable and technically qualified, but also trustworthy. We must be vigilant with respect all those considerations, and be prepared to defend the integrity of our educational and evaluative processes. Our responsibilities extend beyond the individual learner, to the public and to potential future patients.

We must never set wolves among the sheep.

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Learning style quizzes are fun, but they shouldn’t inform teaching

When I completed my Bachelor of Education in the late 1990s, we spent a fair amount of time on learning styles. We explored Kolb’s styles (assimilator, diverger, accommodator, converger) and the VARK model (Visual, Auditory, Reading, Kinesthetic), and ones that incorporated relational aspects (social, independent, introvert, extrovert) in a quest to enhance our skills as educators to best meet our future learners’ needs.

It was presented as a “keys to success” insight – learn how to teach to each student’s preferred style, learn how to modify your instruction to meet every learner’s need, and all would be good.

From the learner’s perspective: figure out how you best learn, seek out learning experiences like that and voila – educational success.

We’ve heard this so often, from multiple avenues, that many of us accept it as an established principle rather than theories. (Just do a Google or an Amazon search and hundreds of sites and books will pop up).

A typical learning style inventory questionnaire and score sheet.

Human beings certainly have preferences – in learning and in all things. I really enjoy lectures. I like listening to someone else talk about an interesting topic and share knowledge and insights. I’ve had the pleasure of having some terrific history teachers, for example, who made things come alive in their storytelling. I learned a lot.

It was, in fact, an experience with a history course that helped me embrace the learning style message and hold it sacred for many years. I loved history and did really well in my high school courses without, I’ll admit, having to try very hard. Except for the unit on the Napoleonic Wars in Grade 11. I was away that week, at a conference, so instead of being in class for about an hour every day, I had the assigned chapters and the teacher gave me copies of his lecture notes. And I bombed the test. Being an auditory learner explained this. I hadn’t heard Mr. A’s lectures, so I didn’t learn as well. It made me feel better about my barely-passing grade, but was it true?

How did I usually learn history? I’d attend the classes (and take notes), read the assigned chapters, and reread my notes to study for the test. How did I do the unit on the Napoleonic wars? I read the assigned chapters and read my teacher’s notes. I actually spent about 50% less time on the unit than any other history unit that year. And I never took my own notes on that unit. Am I really an auditory learner and therefore didn’t test well on something I had to learn differently, or did I spend less time learning this material? Perhaps if I’d read the assigned chapters twice, or taken my own notes, or something else. Auditory learner doesn’t fully account for all variables.

Granted, I’m an n=1, but there’s an increasing body of research (with larger cohorts) that points to learning styles being a “myth”. Myth or not, there’s evidence that using a preferred learning style doesn’t lead to more or better learning. For example, Hussman and O’Loughlin (2018) found no correlation between learning styles and course outcomes for anatomy students, regardless of whether the students adapted their studying to align with their preferred learning style.

Knoll et al (2017) found that “learning style was associated with subjective aspects of learning but not objective aspects of learning.”

The other message in many of these studies: Context is key. Consider my history/auditory learning example, above. Lecture alone would not have gone over so well in an art history class. I may prefer to learn by listening, but isn’t it better to see the paintings rather than have someone describe them? Likewise, even if all the quizzes tell you that you’re an auditory learner, it’s a good bet that it still makes the most sense to learn about radiology using images. And procedural skills are best learned by actually physically engaging in them.

One on-going challenge of the cult of learning styles is it can become an excuse when students don’t master material (“The class didn’t suit my learning style” or “I need to better address students’ learning styles, how do I do that?”). However, a meta-analysis study by Hattie (2012) looked at 150 factors that affect students’ learning and matching teaching techniques to students’ learning styles had an insignificant effect (slightly above zero) (Hattie, 2012:79).

It’s good to remember that, as physicians, our students will have to learn and perform in a variety of ways (styles): reading, listening to people, looking at images of some sort or at patients when examining them, and use their tactile senses when examining patients, as some examples. Teaching them in a variety of ways, rather than using narrowly-focused learning style criteria, can only help them achieve this.

Key take-away points:

  • There are a variety of ways to learn and to teach and context matters
  • Some things are best taught in a particular way
  • We can have preferences for some learning experiences more than others, but we can learn in multiple ways
  • Your preferred learning style may not improve your learning
  • History lectures are always cool.  (They are, but that’s not relevant to this topic, really).

Note on classroom accommodations: Any discussion of learning styles and learning style research should not be confused or conflated with accommodations for learning disabilities or accommodations for physical disabilities which interfere with learning


My thanks to Dr. Lindsay Davidson, Director of Teaching and Learning, for talking through some of the ideas presented in this post.

References:

Hattie, J, 2012, Visible learning for teachers: maximising impact on learning, London, Routledge

Husmann, P. R. and O’Loughlin, V. D. (2018), Another nail in the coffin for learning styles? Disparities among undergraduate anatomy students’ study strategies, class performance, and reported VARK learning styles. American Association of Anatomists. . doi:10.1002/ase.1777

Knoll, A. R., Otani, H. , Skeel, R. L. and Van Horn, K. R. (2017), Learning style, judgements of learning, and learning of verbal and visual information. Br J Psychol, 108: 544-563. doi:10.1111/bjop.12214


Other cool reading on this topic:

From Frontiers in Psychology: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366351/

From The Atlantic:

https://www.theatlantic.com/science/archive/2018/04/the-myth-of-learning-styles/557687/

From the BBC:

http://www.bbc.com/future/story/20161010-do-we-have-a-preferred-style-of-learning

 

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Improving your medical teaching practice one minute at a time

Making changes in how we do things can seem overwhelming – whether these are personal wellness habits, work habits, or teaching practice habits. In the face of a huge list or a major innovation it can seem easier to throw in the towel before you begin.

Sustaining change means adopting new practices and habits that you can stick with.

I recently took a six-week online fitness course that focused on these types of incremental changes. The course is designed for working and stay-at-home moms and recognizes that everybody is really, really busy. Our first challenge was to pick a new habit to adopt that could be easily incorporated into our regular day (I chose skip the elevator—take the stairs). Another challenge was to adopt a one-minute daily task and stick with it – because, as the course leader pointed out: everybody has one minute. I (finally) started doing daily balancing exercises for my multiple-injury-damaged ankles. I’m five weeks in on that new daily one-minute habit, so I think it’s going to stick.

Along the way, I started thinking about one-minute habits and how this could apply to medical education. So here’s my challenge to those looking to improve or change their teaching practice:

Think of one thing that you can do in one minute (a day, or one minute at a time) that could improve your work in medical education. Adopt that one-minute habit. Here are some suggestions:

  1. Immediately after teaching, take ONE MINUTE to jot down quick notes on what you want to change the next time you teach. Do it right after your session, or you may forget what it is.

  2. Create a Med Ed “feel good file” in Google docs or another electronic format (this might take more than a minute): put in things like great feedback fro course evaluations, notes to yourself when something went really, really well with a class or a clerk, notes on teaching things you’re really proud of. If you’re having a bad (teaching) day, pull up the file and take ONE MINUTE to remind yourself of the good things you do as a medical educator.

  3. Reserve the last minute of class, seminar, or rounds to get two-sentence student feedback on index cards – what’s their top take-away from your session/seminar/rounds and what’s their muddiest point right now? Have them take ONE MINUTE to give you this feedback. Over the next week, take ONE MINUTE a day to read through some of the cards. Use the feedback to inform changes to your teaching or to shape a follow-up session.

  4. If you’re logged into MEdTech, take ONE MINUTE to annotate your session objectives on MEdTech. You likely already have these objectives in your PowerPoint slides, so you can just match them up to the assigned ones. (If you have multiple objectives, use your ONE MINUTE to do what you can now!)

  5. Start a teaching ideas journal (could be a notebook, or a word file, or the Notes app on your smart phone). After you’ve read a journal article, or talked with a colleague, or attended a workshop, take ONE MINUTE to write down ideas for how to incorporate this new information into your teaching

  6. Email or phone me and ask for help. No, seriously, do this. True story: While I was writing this post, a faculty member called and said: “Do you have one minute right now for a question?” We might not solve your challenge in a ONE MINUTE phone call, but if not, we can set a time to get together.

Sure, you could take more time on some of these ideas — but not at the expense of feeling overwhelmed by “one more thing” on a big project to-do list. Also, remember, these are suggestions to select from. Don’t take on all of them, because that has potential to turn into an overwhelming, throw-away plan. Pick one or two, or create your own. Because everyone has one minute.

 

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Great Teaching. You know it when you see it.

What makes for a great teaching session? In medical school, we make prodigious efforts to answer that question. We collect reams of information, ranging from the extensive student feedback collected about all aspects of their learning experience, to analyses of objective measures of student success in both internal and external examinations. There is also much written about educational methodology, and which approaches are felt to optimize effectiveness. We establish policy and take effort to ensure those are applied throughout our curriculum.

But beyond all this, there is something about a successful teaching session that defies formal analysis and simply goes beyond the aggregate of measurable parameters. To use a phrase originally applied by a Supreme Court Justice to the understanding of pornography, “you know it when you see it”.

My walking route from the hospital to the undergraduate office takes me by the main lecture hall in the School of Medicine Building at least a couple of times each day. I often stop as I go by to see what’s happening. Sometimes, I’ll drop in and look in on the teaching session for a few minute

It is easy to spot a session that’s going well. There’s a certain energy in the room that is immediately apparent. The students are engaged, attentive, anticipating what’s to come. But even easier to read is the teacher. Whether it’s a basic scientist or clinician, something special happens when a natural teacher encounters a group of eager learners. Like the activation of a long dormant instinct, the encounter seems to set off a response in the teacher that energizes the session. It is no longer a recitation of facts and directives but rather a sincere effort to pass along acquired wisdom. Students, for their part, sense the effort and value of what the teacher is trying to do. They reciprocate with attention that energizes the teacher, setting up a feedback loop that makes the whole thing work.

I’m pleased to report that, by both the objective and “know it when you see it” assessment, the vast majority of the teaching sessions we provide are highly effective. It is also apparent to me that the vast majority of our faculty truly enjoys their teaching experience and finds it personally satisfying. That fact, more than anything, is the source of our success as a medical school.

And it happens a lot. Over the course of our four-year curriculum, over 700 full time and part time faculty members provide teaching sessions to our students, most of them practicing physicians with schedules full of more immediately urgent and financially rewarding pursuits. So how does it happen, and happen so frequently?

In an insightful commentary entitled What Makes a Good Teacher? Lessons from Teaching Medical Students” (Academic Medicine 2001:76(8);809) Ronald Markert identifies several factors that he believes characterize the best teachers. Although all are valid, two have always stood out to me as particularly relevant to the physician teacher. Quoting from Dr. Markert’s article:

 

A good teacher wants to be a good teacher. Teaching has to be its own reward. While recognition for outstanding teaching is commendable, faculty who are motivated only by formal honors will not achieve teaching excellence.

The focus of instruction should always be on student learning, not faculty teaching. Too often faculty members concentrate on what they want students to know. However, medical education is professional education, and we who teach medical students should go beyond our conceptions of what we think they should know and instead should search for what they actually need to know as practicing physicians.

 

Teaching, at its core, is a distinctly human interaction. It requires a connection, a mutual, unspoken relationship between two parties, one possessed of knowledge and the generosity to share, and one receptive to that knowledge. Essential to the learner is trust. They must assume their teacher is not only knowledgeable but is also motivated by their best interests.

Doctors are natural teachers. I believe this is, at least in part, because the selfless sharing of information and focus on the needs of the learner so well-described by Dr. Markert are also features of the physician-patient relationship. They also instinctively understand the concept of assumed trust, as critical to the teaching role as it is to provision of care to patients.

This week at medical school convocation, the graduating class will honour three such great teachers whom they have identified to receive the Connell Award. Named in honour of two previous heads of medicine, this award recognizes outstanding contributions to mentorship, lectureship and clinical teaching over their medical school experience. This year, Drs. Susan Moffatt, David Lee and Barry Chan have been selected and are, indeed, very worthy recipients.

 

 

Congratulations to them, and to all our faculty who contribute their time and natural talents to not only educating our students, but modelling for them the commitment and teaching skills that they will carry into their careers.

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Curriculum Committee Information – March 22, 2018 & April 17, 2018

Faculty, staff, and students interested in attending Curriculum Committee meetings should contact the Committee Secretary, Candace Miller (umecc@queensu.ca), for information relating to agenda items and meeting schedules.

A meeting of the Curriculum Committee was held on March 22, 2018 and April 17, 2018.  To review the topics discussed at this meeting, please click HERE to view the agenda for March 22, 2018 and HERE to view the agenda for April 17, 2018.

Faculty interested in reviewing the minutes of the March 22 and April 17 meetings can click HERE to be taken to the Curriculum Committee’s page located on the Faculty Resources Community of MEdTech Central.

Those who are directly impacted by any decisions made by the Curriculum Committee have been notified via email.

Students interested in the outcome of a decision or discussion are welcome to contact the Aesculapian Society’s Vice President, Academic, Justine Ring at vpacademic@qmed.ca.

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Learning through Community Service: From the classroom to Rideau Heights.

“Education is not preparation for life. Education is life itself.”

Those words are attributed to John Dewey (1859-1952), an American philosopher-educator who argued persuasively that the purpose of education is not simply to prepare young people to earn a living, but also to gain a deep understanding of the society in which they live and how they can function and contribute to it. In fact, he believed that achievement of a “democratic” society was not possible without that deep understanding, and that it could only be gained through personal experiences (Dewey J. Democracy and Education: An Introduction to the Philosophy of Education. MacMillan. 1916).

In the medical world, its axiomatic that doctors require a full understanding of the patients they serve. That understanding must go beyond the physiology and pathology of their medical diseases and extend to the circumstances of their patient’s lives and how those circumstances influence the genesis and treatment of their medical ailments.  If medical education is to prepare students fully for this challenge, it can’t be achieved simply through expressions of commitment and recitation of facts. It requires personal encounters and lived experiences.

The concept of “service learning” in medical education is fundamentally a commitment to provide those experiences. The challenge, of course, is that it can’t be forced upon the unwilling. Medical schools need to firstly select young people in whom the consciousness of community service and social accountability already exists, and to then provide opportunities in which fruitful educational encounters can develop. Basically, we outline the concepts and point to opportunities. It’s up to our students to take up the challenge. And they do, which, I must say, is one of the most satisfying and affirming experiences for any medical educator.

A few weeks ago, I had opportunity to drop by just such an event. It occurred at the opening of the Rideau Heights Community Centre, a facility established by the city to serve an area that has been considered underserviced. Our students, through linkages established with the Loving Spoonful, a Kingston agency committed to providing healthy food security, had opportunity to contribute to that event. I’ll let them describe the experience in their own words, written by the lead organizer, Danielle Weber-Adrian of Meds 2021 (photos courtesy of Danielle and myself).

 

Last November 4th there was a Health and Human Rights weekend seminar hosted at the School of Medicine Building. This is where I met Mara Shaw (Executive Director of Loving Spoonful) and we started chatting in a food security workshop. During graduate studies, my class fundraised for and hosted a meal at a local soup kitchen. It had been a wonderfully rewarding way to engage with the local community, and I thought the class of 2021 would also enjoy something like this. I pitched the idea to Mara and she immediately said yes. She mentioned that the opening of the Rideau Heights Community Centre would be the prefect venue for this idea. She explained that the demographics of the Rideau Heights neighbourhood included some of those most in need in the Kingston area, and that she’d love to work with us. 

Getting the class on board was a cake walk. Bethany Ricker was also at the seminar and she was the first person I approached about this idea. She showed immediate interest and the two of us formed the Rideau Heights Community Meal Committee. After that, five more of our classmates were avid to join the team and we were “off to the races”! Mara put us in touch with a local culinary chef, Tibrata Gillies, and assigned Thea Zuiker from Loving Spoonful to help us organize logistics. Bethany had been a cook at a summer camp before medical school, and the chili was actually her idea. She also single-handedly secured sizable donations of ground beef and vegetables to support our efforts. Tibrata then guided us as to how to prepare our meal, scale up a recipe, and then lead us on the day-of. When I had originally spoken to Mara about this I thought we were going to make a meal for about 200 people, but she told us we were expecting closer to 500 (“if that would work for us”). So, the committee rallied fundraising efforts and took on the challenge! To help mitigate costs, Emily Wilkerson and Bethany spear-headed a mini telephone campaign targeting local bakeries and grocery stores to inquire about bread donations (this was ultimately unsuccessful, but speaks to their resourcefulness and ingenuity!).

Fundraising started in full force in January, and it was a true collective effort. Emily  organized a 50/50 draw during a mentorship trivia night, which was wildly successful. Natasha Tang, Sarah Wong, Emma Spence, Angela Brijmohan and Bethany Ricker planned weekly (or biweekly) bake sales and organized volunteer bakers, and I sold “all you can drink” coffee most mornings until we had raised $974.60. Meanwhile, Emma had the fantastic idea of applying for the ASIA (Aesculapian Society Initiative Award) through which we were awarded another $900. This was almost double our initial fundraising goal of $1,000. 

For the event itself, Loving Spoonful was a dream to work with. Once we had delivered the funds, they contacted a grocery wholesaler and had most of the food delivered right to the community centre, meaning I only had to make one trip to Walmart for plates and a few other essentials to prepare for the meal. Loving Spoonful was also in contact with the city while designing and planning the community centre kitchen, so they knew exactly what we would have available. Tibrata also got to weigh in and advise the city which kitchen hardware options to invest in. 

In the end, we were able to provide a warm, nourishing meal for over 500 Rideau Heights community members, and we had plenty of 2021 (and 2018!) volunteers to cook, serve, and clean up. It was a fantastic experience, and I’ve heard really great feedback from both the class and the event participants. 

 


The School of Medicine Building on Arch Street and the Rideau Heights Community Centre are separated geographically by 4.2 km. Culturally and socioeconomically, the separation is much greater. The students who took the initiative and made the effort to serve the families of north Kingston closed that gap and, in the process, both confirmed the wisdom of our admissions process and made great strides in their journey to becoming great physicians. In short, they did us proud. Congratulations to them.

 

 

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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“What Happened in Medicine?” Medical students ask Philadelphia

By Kelly Salman, photos by Rawy Shaaban, Queen’s medicine class of 2021

“The history quiz is due this weekend?!” a classmate pulled it up on his phone, while a few followed suit on laptops. We were waiting for the bus to take us to Philadelphia and while my peers debated the turbulent past of drug advertising, the rest of us talked about what we were excited to see. Many had plans for dramatic poses on the “Rocky steps” or near the Liberty Bell.

“What even is the liberty bell?” I shamelessly asked while googling the best spot to find cheesesteaks. The real reason we were heading over the border was for a history of medicine trip, the continuation of a long tradition for Queen’s Medicine students, one that started in 1996.

I can’t lie and say I’ve always appreciated history. Although I could fool you, or scare you, with my wide-eyed ramblings about how cool the plague must have been, history is an interest I’ve found late. But along my route to medicine, something romantic about the past has drawn me in, and I got the impression during this trip that I wasn’t alone. Perhaps it has something to do with entering a field that makes you take an oath to an ancient Greek guy, but as a group medical students seem somewhat enamoured with their own history.

Contrary to popular belief, history waits for no one, and we started our adventure early Saturday morning, coffees in hand. Pennsylvania Hospital was a great place to set the tone; I challenge anyone to sit in an old surgical amphitheatre and not get swept up in historical daydreams. It helped that our guide painted an incredible picture for us as we sat on elevated benches, peering down at a classmate sprawled out on the operating table. It’s the details that get you… for instance, the floor would have been covered in wood chips for soaking up, well, you can imagine. Or that the hospital opened its doors to those of the public curious to observe the spectacle. In a different life, I wondered, how many of us would have been in that audience.

We continued to a stately mansion, famous for housing a man modestly named “the Father of American Surgery”, or to his friends and family Dr. Philip Physick. The guide here had a slightly more blunt approach, but it fit with the narrative he was giving. As we perused Dr. Physick’s various inventions (surgical instruments and… soda), he told us about how uncommon it was for a patient to survive surgery in those early days of the field: “He tried some neurosurgery, but often ended up accidentally nicking a blood vessel and then it’s ‘you’re going to get very sleepy now’”. I left with the unsettling impression that surgery in the 18th century sounded a lot like making a recipe from scratch – trial and error.

If you’ve ever idly wondered what a slice of Einstein’s brain looks like, then the Mütter Museum is for you. So, basically everyone. It’s a medical smorgasbord, filled with oddities and ailments through time: atypical skeletons, preserved organs, a jar of human skin (why?!), and even a giant human colon. Perhaps more interesting was the history of how society responds to such anomalies, in an exhibit dedicated to the folklore and varied cultural attitudes surrounding birth defects across the world. No photos allowed, but check out their website for some extraordinary highlights!

As millennials we often forget what books look like, so it was a real treat to see the libraries. We marvelled at the mahogany grandeur of the Pennsylvania Hospital library, but my favourite was less insta-worthy (partly because pictures were ‘discouraged’). While half of the group looked through beautiful, hand-drawn anatomy pop-up texts, the rest of us were led along a meandering pathway through the College of Physicians of Philadelphia to a door reminiscent of a submarine airlock. We quietly filed into the largest collection of books I have ever set eyes on. It was a room of steel bookshelves, dusty and dimly lit, filled with medical literature and journals from the past. Peering through the holes in the floor, the stacks continued infinitely further down than my eyes, and frankly my brain, could comprehend. I tried to imagine all of the words below our feet, and thought it must be akin to what an astronaut feels looking back at the earth.

I know my words can’t compete with those of my medical ancestors hidden away in Philadelphia. But hopefully if you take anything from them, it’s an inkling of interest into the world behind us. Good and bad, whimsical, and downright gruesome at times, the history of medicine is incredibly important. Because, well, in the words of someone more eloquent than me “History never really says goodbye. History says ‘See you later.”

Oh and in case you were concerned, I did find time for a cheesesteak.

 

 

 

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Now what? Making the most of a conference, now that you’re home

Many of us from Queen’s UG – faculty, staff and students – are just returning to campus after a few days in Halifax, NS for the annual Canadian Conference on Medical Education (CCME).

CCME brings together those involved in all aspects of medical education from across Canada and beyond for workshops, meetings, plenaries, research orals and posters, and general sharing of innovations and challenges.

Like most jam-packed conferences, the information overload can be overwhelming. Here are five ways to make the most of your conference experience, once you’re back home:

  1. That Bag O’Stuff: If you didn’t do this prior to packing to come home, take two minutes to sort the “stuff” acquired at the exhibitors’ hall, at the poster presentations, and handouts from workshops. Are you really interested in that program/service/product/innovation or did you add it to your bag from habit? I sort my conference bag while standing over the recycle bin and keep only things I’m going to follow-up on. Put what remains aside for tip #2.

  2. Get out your Post-Its! For everything that’s left from your paper purge, put a note on it RIGHT NOW. In two weeks you’ll forget exactly why you picked that up – especially if you thought it might be of interest for a colleague. Write yourself those notes!

    Hmmmm. Why did I take this picture? Do I need to save it? Sort your files right now!
  3. Sort 2: Electronic edition: Did you use your smart phone to take pictures of posters or of presenter’s slides that spoke to you? Move them to a labelled folder NOW and offload to your computer to ensure they don’t get lost amongst your upcoming summer shots. Label things a la electronic stickies (see #2)

  4. Follow-through: Did you collect emails from anyone you met along the way? Did you make tentative plans to get together, pursue a project, or generally stay in touch? Send off that quick networking email now, before those potentially productive contacts are lost in the busy of day-to-day responsibilities.

  5. Plan ahead: Mark your calendar now for next year’s CCME in Niagara Falls April 16-19, 2019. (Abstracts open later this month!)

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Why medical students go unmatched, and why they deserve an opportunity to complete their training.

There is no longer any doubt that the number of unmatched Canadian medical graduates is on an upward trajectory that will certainly continue in the absence of significant interventions. We now know (https://afmc.ca/news/2018-04-17) that 115 students remain without residency positions after two attempts to “match” this year. That’s an increase from 68 from last year, 46 in 2016, and 39 in 2015, which means the number has almost tripled over those four years.

We also know of the tremendous individual burden of failing to engage a residency position which, while always very well understood by medical students and medical school faculty, has been made public through numerous articles and individual accounts:

https://atlantic.ctvnews.ca/medical-students-go-unmatched-despite-doctor-shortage-1.3884737

https://meds.queensu.ca/ugme-blog/archives/date/2017/06

https://www.thestar.com/news/canada/2017/06/17/tragic-case-of-robert-chu-shows-plight-of-canadian-medical-school-grads.html

https://www.universityaffairs.ca/features/feature-article/canadas-medical-residency-system-leaving-graduates-limbo/

Both the Association of Faculties of Medicine of Canada (AFMC) and Canadian Federation of Medical Students have developed position papers on this issue.

https://afmc.ca/sites/default/files/documents/en/Publications/AFMC_reportreducingunmatchedcdnmg_en.pdf

https://www.cfms.org/files/position-papers/agm_2017_support_unmatched.pdf

The upward trend is in keeping with the rather dire predictions of the AFMC position paper and has caused that organization, in a recent news release, to term the situation a “crisis”.

https://afmc.ca/news/2018-04-17

It has also spurred the Ontario Minister of Health, with urging from the provincial medical school Deans, to introduce a 23 million dollar program to provide supernumerary positions to, at least temporarily, provide relief.

https://news.ontario.ca/mohltc/en/2018/04/ontario-funding-additional-residency-positions-for-medical-graduates.html

This effort by our provincial government is very much welcome by both students and medical school faculty, and certainly provides very tangible evidence that the issue has gained attention and is being seriously engaged. However, it is clearly a temporizing measure, intended to stop the bleeding, not resolve the problem.

In medicine, we teach that problems can only be effectively engaged with a full understanding of their cause, or etiology. That process always starts with an examination of available facts, which are sometimes difficult to tease out from the subjective impression of a stressful experience.

So, what are the facts?

  • The number of residency positions available to medical school graduates is established by our provincial governments. They also very strongly influence the distribution of those positions between the 30 or so entry level residency programs. This is entirely appropriate to their responsibility to safeguard the public interest, both in terms of provision of health care and financial stewardship. No doubt they and their advisors make every effort to ensure that those positions match the needs of the communities they serve. Given the lag time inherent in the medical education process, this requires predicting future needs which, all would agree, is a difficult and inherently imprecise process.
  • Provincial governments have also made the decision to make some residency positions available to Canadian citizens and landed immigrants who have graduated from medical schools outside Canada (International Medical Graduates).
  • Students enter medical school with the clear expectation that any medical specialty is available to them but with little idea of which medical specialty they wish to engage, and with no obligation to undertake any particular specialty. Considerable effort and thought is expended by students during medical school to make those determinations. Those efforts are strongly supported by undergraduate programs through counseling and provision of career exploration opportunities.
  • Medical students make their own choices with respect to which programs they apply to, and how many programs they apply to. In doing so, they receive counseling from their schools, but are free to accept or reject any recommendations, and are well aware of which residency programs are more competitive.
  • Although the absolute number of residency positions is numerically similar to the number of Canadian graduates, the choices of students do not match the distribution of positions, resulting in a number of specialty programs being heavily over-subscribed and therefore highly competitive.

 

The phenomenon of the unmatched student is therefore the direct consequence of a mismatch between the specialty mix deemed to be in the public interest by our government, and the personal preferences of students.

It is also clear, given the current process and recent history, that the goal of matching every student to their specialty of choice is an impossibility. Intense competition for residency spots and increasing numbers of unmatched students are inevitable unless one or more of the operative realities noted above are changed. Fortunately, the Ministry of Health has, in the recent statement, committed to engage substantive change:

Ontario is collaborating with partners throughout the country to develop and implement a longer-term solution to this pan-Canadian challenge.”

Those charged with developing this “longer term solution” will, no doubt, be facing a considerable challenge, attempting to balance the government’s primary responsibility to public accountability, with the full freedom of students to choose any specialty. As they do, they will need to consider a few other facts concerning the educational experience of our students.

Medical school graduates are not yet able to engage practice. Medical education is a continuing process that transitions from university-based degree programs to residency positions that last a minimum of two additional years and which must be completed before a learner is even eligible to engage practice. While it is certainly possible for medical school graduates to take up alternate careers, that is clearly not their intention at outset, nor is it the societal expectation that establishes the number of medical school positions to match needs and heavily subsidizes medical education. The graduate who fails to achieve a residency is therefore denied the opportunity engage medical practice, and the training they have received to date is essentially wasted.

One could argue persuasively that the public interest, honestly and objectively interpreted, should always take precedence over individual preferences. However, most would also agree that every individual in a free society should at least have the opportunity to engage the profession for which they have undertaken training at considerable effort and personal sacrifice, and for which they have successfully demonstrated qualification.

Our students deserve the opportunity to engage a career in medicine and our society deserves a return on the investment they’ve made in their education. For those things to happen, our graduating students must have an opportunity to engage a residency program. Our ultimate solution to the unmatched student problem must, at a minimum, provide that opportunity.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Third annual History of Medicine Week starts April 23

The What Happened In Medicine (WHIM) Historical Society is proud to host the third annual History of Medicine Week! This year’s theme is inspired by Dr. Duffin’s Heroes & Villains assignment, where students must grapple with some controversial characters in our history. Students, Faculty, and Community members are all warmly welcomed to attend any and all events! Please join us during the week of April 23rd for four exciting events:

Museum of Healthcare Showcase 

Monday, April 23rd (8:30AM – 3:00PM)
Grande Corridor, New Medical Building, 15 Arch St.

Hero or Villain? You be the judge! Wander through the Grand Corridor of the New Medical Building and enjoy the showcase curated by the Museum of Healthcare. At your leisure, take a look at artifacts of some of history’s biggest medical heroes and villains.

Panel Discussion

Tuesday, April 24th (5:30PM – 7:30PM) 
132A, New Medical Building, 15 Arch St.
Don’t miss out on our most controversial event of the week! After a half hour period to gather refreshments and FREE food, a panel, moderated by the incredible Dr. Jenna Healey, resident Queen’s Hannah Chair of the History of Medicine, will question the basis for a designation of hero or villain. The panel will begin with Dr. Jaclyn Duffin, haematologist, historian, and past Hannah Chair of the History of Medicine, describing why and how she invented the Heroes and Villains project as an introduction both to history in medicine and to information literacy — with some of its triumphs and disasters. Next, Dr. Allison Morehead, Associate Professor and Graduate Coordinator of Art History at Queen’s University, will talk about Florence Nightingale and the “incursion” of women into the “fraternity” of medicine in the 19th and 20th centuries, as well as the ways in which historical accounts of Nightingale heroicize (or angelicize!) her to the exclusion of other figures in the history of nursing, such as Mary Seacole. Closing the panel is Edward Thomas, PhD candidate in Cultural Studies at Queen’s, will discuss his research examining Queen’s barring of black medical students between 1918 and 1964 in regards to how institutional narratives shape organizational memory and culture. 

Open Mic Night 

Wednesday, April 25th (7:00PM – 9:30PM)
The Grad Club, 162 Barrie St
Need an outlet for your historical arguments? Ready to re-enact your heroes and villain assignment? Want some free beer and endless historical entertainment? Come out to the Heroes & Villains: Open Mic Night! A relaxing event, some fantastic entertainment, and a wonderful evening spent with your Queen’s peers, what more can you ask for?!

Movie Night: History of Kingston Psychiatric Hospital

Thursday, April 26th (5:30PM – 7:30PM) 
032A, New Medical Building, 15 Arch St.

Don’t miss out on this weeks closing event! We will be screening the film “The History of KPH” by Queen’s Film Studies’ own Janice Belanger. Come to learn more about the Kingston Psychiatric Hospital, and have a relaxing end to this jam-packed week!

 

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