Bats, Blogs, and Story Ideas

While I was drafting this post, I had an unexpected visitor in my office in the form of a juvenile bat. Yep. A bat.

I followed the Queen’s Environmental Health & Safety bat protocol (yes, there is one. Find it here) and exited the room immediately, closing the door. I then had a colleague call to arrange for its removal.

Ok, there may have been some squealing-like-a-five-year-old while I was exiting the room, but since there was nobody here to see that, I can deny it happened (colleagues’ vacations and meetings were well-timed for my dignity). There may also have been some vocabulary that would earn a fine for the curse jar at my house.

Just a handful of people would know about my bat adventure… except I’m writing about it here.

My point is this: things happen all the time around the UGME offices, the medical building, and other places of importance for the UG program. Things for, to, or by our faculty, staff, and students; interesting things that are worth sharing. I’m not suggesting that we’re starting a weekly newspaper filled with notations of every bat sighting, or intramural sports scores. What I do know, however, is there are plenty of newsworthy things happening that go unnoticed.

Things like: innovative student activities or projects; research publications; special events; noteworthy field trips; students or faculty winning awards. If you’ve ever wondered why we posted about “X” but not about “Y” the simple reason most of the time, is we likely didn’t know about “Y” at all.

You may have noticed a bit of a pattern to our blog posts. Our associate dean, Dr. Sanfilippo posts roughly every other week. On the alternating weeks, members of the Education Team post, with the occasional committee update thrown in. I post under my own name, as well as curating those posted under the “Guest Blogger” ID.

Here’s where you come in. If you’re a member of the Queen’s UGME community and you have an idea or suggestion for a blog post, please feel free to get in touch. We could write something up with you as the source, or you could write the post yourself as one of our Guest Bloggers.

If your suggestion is time-dependent (like an event or something with a deadline), try to get in touch as early as you can.

I can’t promise that we’ll be able to follow-up on every suggestion with a published post, but a great starting point is letting us know. So, get in touch. Reach me by email (theresa.suart@queensu.ca ) or drop into my office on the 3rd floor at 80 Barrie. It’s currently bat-free.


Bat shown is for illustration purposes only… no pictures of my recent temporary office guest are available. 

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Life Lessons from an Unlikely Hero

Every sport, in fact every area of human endeavor, affords opportunities for heroes to emerge in dramatic fashion. In hockey, it’s the game winning overtime goal. In basketball, it’s the desperate long range shot with no time remaining that arches high over the court, seemingly suspended in space and time, before gracefully falling through the hoop.

In baseball, it’s the walk-off home run. This occurs when a batter, in the ninth inning, hits the ball out of the park assuring victory for his team. It’s called “walk-off” because it ends the game and all players depart – losers dejectedly, winners in joyous celebration. When there are runners on every base, it becomes a “grand slam” home run, adding further to the drama and celebration.

Among the more than 18,000 athletes who have played professional baseball since it’s inception in 1876, only two have hit multiple grand-slam walk-off home runs in a single season. That is, until a couple of weeks ago, when Steve Pearce of the Toronto Blue Jays did just that, during a single week of play.

When these moments happen to those who have already achieved prominence, it seems the natural extension of a pattern of excellence. But when it happens to someone previously unheralded in their field, it can be particularly sweet and revealing. Such is the case with Mr. Pearce. He is not a baseball superstar. He is not even a star. He has been described by those far more knowledgeable than I as a below average defensive player. He has, in fact, been characterized as a “journeyman” or “utility player”, which sounds like the sporting equivalent of a spare part that one might search for at the auto junkyard.

He was chosen in the 45th round of the 2003 major league baseball draft, meaning approximately 1200 players were chosen ahead of him. This is like being the last kid standing when your playmates are choosing sides for a game – “OK, we’ll take him, but you have to give us somebody good too”. He actually re-entered the draft twice, finally signing with the Pirates in 2005. Over his career he has played for no fewer than 8 teams. He didn’t start a season in the majors until 2011. In 2012, he played for three different teams. In his best year, 2014, he had 21 home runs, 49 RBIs and a .293 batting average playing for Baltimore. Respectable figures, to be sure, but far from spectacular. He is described by sports writer Cathal Kelly (Globe and Mail, July 30, 2017) as someone possessed of an “intense averageness”, with “no veteran swagger”. He is, by all accounts, unpretentious and well liked by his teammates – a hard worker and team oriented contributor who appreciates the opportunities he’s had to make a living in his chosen occupation. His response to his recent accomplishment and celebrity was, to say the least, modestly measured and understated. His teammates seemed genuinely pleased about his unexpected notoriety, evoking a sense of justice for the common man.

But Mr. Pearce hasn’t always been a common man. Growing up in Florida and attending the University of South Carolina, he was an outstanding athlete, excelling in multiple sports, but particularly baseball where he led his teams, set performance records, and won multiple and significant personal recognitions for his accomplishments. In fact, it wasn’t until he entered the major leagues that his “averageness” became apparent.

Despite all this, Mr. Pearce has survived in a highly competitive occupation, has earned (according to baseball_reference.com) almost $17 million in total salary, is highly respected by his peers and, this past week, injected joy into what has otherwise been a decidedly joyless season for followers of Toronto baseball.

So, you’re wondering, how does this story find its way into a blog about the education of doctors?

In about three weeks, we will be welcoming a new class to our medical school. Those young people have been accepted based on very impressive personal academic and non-academic accomplishments. They have known much success and have experienced much external approval. In that sense, they are not unlike Mr. Pearce as he began his professional career. They will find, as do all successful professionals, that their natural abilities are essential but not sufficient to achieve career success and personal satisfaction. They will need to define for themselves their concepts of success and worth. They will need to find their place within their new community of peers and teachers, and their way to make contributions within their chosen profession. They will need to find ways to engage and overcome adversities that will invariably come their way. They will, no doubt, have “grand slam home run” days, but must be equally content with the days of unheralded, honest effort.

These are life lessons, and the exclusive domain of no particular group. They will not be found in any formal curriculum. The term “hidden curriculum” has taken on very negative connotations, but it can also be a very positive force, providing that informal but vital exchange that occurs between students and their teachers that models and promotes professional development.

I don’t imagine Mr. Pearce thinks of himself as a teacher of aspiring physicians, but his perseverance and equanimity in the face of both adversity and success are an example to us all.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Rerun season nostalgia and course planning

In the era of Netflix, TiVo, and Internet downloading that has given rise to binge-watching an entire TV series in a weekend, my childhood appreciation for summer rerun season is distinctly absent.

For those of a certain generation, summer was the time to catch-up: on sleep, on reading, on those episodes of your favourite TV show that you missed because of basketball practice or drama rehearsal (or because your brother got to pick his favourite show alternating Tuesday nights).

While reruns may be absent from your television set, the concept of reruns can be helpful in your course planning for the fall. As you review your teaching, consider these things:

  • What were the highlights? (80s Rerun Parallel: A great episode you want to see again)
  • What did you include but didn’t cover as closely as you wanted? (80s Rerun Parallel: That awesome episode you half-watched while playing Candy Land while babysitting)
  • What got dropped by accident? (80s Rerun Parallel: The special episodes you missed because you just couldn’t get to the TV at the right time—see reasons, above).

These rerun-inspired reflection prompts can get you thinking of areas where you can improve or enhance your teaching plan. And, in the spirit of retro TV-rerun season, here are four of my previous blog posts you may have missed that give you some tools for planning or revising your teaching after your reflecting is complete:

Now, excuse me while I try to figure out the scheduling of binge-watching six seasons of Game of Thrones so I can get caught up. I seem to be one of the only people around who hasn’t watched a single episode.

But, seriously, I’m always available to talk through your UG teaching challenges. Email me: theresa.suart@queensu.ca

 

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When teaching isn’t fun anymore…

People come to teaching through a variety of paths. That’s especially true in medical education.

One thing that most educators – at any level – have in common is a sincere desire to teach. And, generally, most educators get some enjoyment out of it. But what happens if that’s not the case? What if you’ve been told you must teach, or (perhaps more disheartening), what if you’ve enjoyed education assignments to this point, but teaching just isn’t fun anymore?

Even if it’s something you have been passionate about, it can be a challenge to stay engaged year after year. Even the most dedicated educators can lose steam along the way. (These suggestions aren’t focused on the level of burnout. That’s another very serious topic for another day. This is more about a “general malaise” – you know there’s something not working, but you’re not quite sure what that is.)

If your enthusiasm for your teaching assignment is on the wane, and it seems more chore than challenge, here are five possible interventions to consider:

  1. Re-focus on what attracted you to teaching in the first place. (Or, if you’ve been assigned to teach, think about what you enjoyed about learning).

What brought you to teaching in the first place? Is it sharing knowledge and expertise? Working with future colleagues? Exploring new technologies or teaching methods? Is it the place, the people, the content? Sometimes we drop our favourite things by accident. Is there something missing now that you can reintroduce to your teaching practice?

  1. Team up with a colleague.

Despite the many faculty we have, teaching can seem a lonely enterprise. Preparation is very often done solo and it’s you standing alone with the class or group of students. Consider partnering with a colleague to prepare together and compare notes after teaching. You don’t have to be teaching in the same course or area – it’s staying connected and sharing viewpoints that can help.

  1. Swap assignments.

If you’re able to, consider swapping teaching responsibilities with a colleague: if you’ve always focused on pre-clerkship teaching, maybe trade with a colleague who has focused on clerkship instruction. If you’ve been an FSGL tutor, swap with a Clinical Skills one. The shift in perspective could help you both (and enrich students’ experiences, too). If you pair this with #2, you can help each other through the transition. When you swap back the next year, you’ll each have new tools and a fresh outlook.

  1. If you can, step away for a little while.

While this is not always possible, if you can take a break from teaching, it can reawaken your enthusiasm. Time away can help you remember exactly what it is you love about teaching and give you space to address those areas that have become chores. Sometimes absence truly does make the heart grow fonder.

  1. Come talk to me or other members of the Education Team.

We may be able to help pinpoint specific areas of your teaching assignment that are dragging you down and brainstorm some solutions. Sometimes talking it out can provide its own insight. We don’t have all the answers, but we can certainly help look for them. Reach me here: theresa.suart@queensu.ca

 

 

 

 

 

 

 

 

 

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Teaching, Learning and Integration Committee Summer Update

By Lindsay Davidson, Director of Teaching, Learning, and Integration

As classes (at least in years 1 and 2) have now ended, and teachers are perhaps thinking about courses that will resume in the fall, I wanted to provide you with an update of items from the TLIC. Some of these may already be familiar to you, but perhaps some are “new”. If you need any further information, please feel free to contact me directly or one of our Educational Developers (Theresa Suart from Years 1 and 2 and Sheila Pinchin for Clerkship and the “C” courses).

  1. Resources attached to learning events – these include lecture notes, classroom slides, required pre-class readings and optional post-class readings/resources. MEdTech is enabling a new feature for the upcoming academic year. Teachers will be required to review and “publish” each resource every year – with the option of adding in delayed release if appropriate. The goal of this is to provide students with an up-to-date, curated set of resources, deleting old files. Please direct any questions about this to Dr. Lindsay Davidson.
  • Remember: “less is more”: Students report that when there are an excessive number of files, they often read few/none of them in advance.
  • Clearly designate what is MANDATORY to review PRE-CLASS by indicating this in the “Preparation” field on the learning event, and checking the appropriate boxes on the menu when you review the resources.
  • AVOID using dates on your slides/slide file names – students are sometimes disappointed to see that the file dates from 2009 or prior.
  1. The Curriculum Committee has approved a new learning event type – “Games” – reflecting several sessions already existing in the curriculum. This is defined as “Individual or group games that have cognitive, social, behavioral, and/or emotional, etc., dimensions which are related to educational objectives”. This type of activity might include classroom Jeopardy or other similar activities designed to allow students to review previously taught knowledge (content delivered either independently or in the classroom) and to provide them with formative feedback on their understanding. The instructional methods approved by the Curriculum Committee include:

Please direct any questions about this to Theresa Suart.

  1. Workforce – The Workforce Committee has recently adopted some changes including the following:
  • Addition of credit for teachers who grade short answer questions or team worksheets
  • Doubling of credit for teachers who develop new (or significantly renovate) teaching session
  • Limit of one named teacher per DIL event
  • Limit of one teacher per SGL event (gets additional credit to reflect session design, learning event completion, submission exam questions); additional teachers credited as tutors (credit for time in the classroom) – the Course Director may be asked to clarify who is the “teacher” and who is/are the “tutors”
  • Reduction of credit for large classroom sessions (that are not new/newly renovated and/or do not involve grading)

Please direct any questions about this to Dr. Sanfilippo.

  1. Tagging of Intrinsic Role objectives. The TLIC and the Intrinsic Role leads recently held a retreat. One of the items that was identified was “overtagging” of sessional objectives with intrinsic role objectives such as communicator, collaborator, professional etc. by well meaning teachers. We are undertaking a comprehensive review of how these Intrinsic Roles are taught/assessed in the curriculum and would ask teachers/course directors NOT to tag sessions with these unless there has been a direct communication with the relevant Intrinsic Role lead.

Please direct any questions about this to Dr. Lindsay Davidson.

  1. DIL feedback from students. Over the past year, we have received useful feedback from students regarding the content and structure of Directed Independent Learning (DIL) sessions in Years 1 and 2. This will be collated and communicated to Course Directors shortly. Theresa Suart will be in contact with teachers/Course Directors should any sessions be identified for review/revision.
  2. Online modules. We have developed a process to facilitate the development of high quality online modules, often used as resources in DIL session. These are highly appreciated by students and are used for review in clerkship as well as pre-MCC exam. The current list of modules is available here: https://meds.queensu.ca/central/community/ugme_ecurriculum If you would like to create (or revise) a module for your course, please complete the linked intake form: https://healthsci.queensu.ca/technology/services/elearning/online_learning_modules/get_help
  3. New wording of learning event notices. You may have noticed this over the past year. The wording of the 3 email notices received by teachers has been revised. In particular, it has been streamlined and customized to provide specific, focused reminders prior to the scheduled teaching. We would appreciate any feedback or suggestions that you have about this change.
  4. Video capture In 2016-17, lecture sessions were video captured in select year 1 and 2 classes. We will be analyzing how these videos were used by students over the summer and will likely be continuing this into the fall. Please provide any feedback or comments that you have about this pilot to Theresa Suart.

Feel free to get in touch:

 

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Chill out, Zio

The sign on the door clearly said the store should have reopened at three. According to my watch, and confirmed by my cellphone, it was now 3:12. I’d been waiting a full 3 minutes.

The place where I was waiting wouldn’t really qualify as a “store” as we would understand the term. It was really a ground level room of a three-storey home on the main street of the small Sicilian village I was visiting for my niece’s wedding. It was attached to rows of similar buildings that lined the narrow main street where most of the other ground level

Photo courtesy Peter Sanfilippo

rooms had been similarly converted to a variety of businesses – grocery stores, flower shops, bakeries, espresso bars, and other purposes I couldn’t discern based on outward appearances.

This particular “store”, I was assured, was the only place I might obtain a media card, the object that was apparently preventing my cellphone from being able to store more pictures. Fabrizio, who operated the store, would know what to do.

Looking through the glass, I became dubious that I’d find any solutions among the apparently random collection of items in the small, cluttered space. It seemed more like a workshop than a place of business. In fact, I wasn’t sure how more than one person would even fit inside.

I turned to my niece who had come along to help me find the store. As the central figure in the aforementioned wedding, which promised to be the social event of the season, she certainly had better things to do. But here she was, remarkably calm despite the circumstances and lateness.

“Where is he?” I asked, with righteous agitation.

With an expression one might reserve for calming a hyperactive child, she turned her big brown eyes to me and said with barely disguised condescension:

“But Zio, he lives upstairs. He’s having lunch with his family”.

And there it was. Crystallized in those few words, expressed by this young and vibrant woman, all the differences between her world and mine came into sharp focus.

In her world, people were simply not ruled by any clock or regulation.

In her world, people choose to spend their time doing what is valuable to them, and are unapologetic in doing so.

In her world, people not only take time for lunch, but truly value that time despite what we might regard as greater priorities.

In her world, the choice to value private time over work is not simply tolerated, but understood and respected.

Her world has trust and comfort in its way of life, and regards our work-obsession with a combination of amusement and pity. It’s a world that says, without rancor, but in no uncertain terms, “you’re here now – chill out, because we’re not changing.”

This is not a new realization for me. The contrast between the lifestyles of my ancestral and birth homes becomes apparent whenever I visit, but my understanding has changed, perhaps matured, over the years. What I previously regarded as a quaint, anachronistic way of life out of keeping with the modern world, I now see as an explicit and insightful choice, particularly when made by bright young people like my niece and her fiancé (now husband) who are choosing to remain and begin their lives there.

There is, of course, a price to be paid for this less-than-compulsive approach to productivity. The Italian economy is a continual source of concern to both its leadership and the international community.

From The Italian Job. The Economist.com, July 9, 2016.

 

Despite this glum outlook, Italian health indices, life expectancy, quality of life and “happiness index” rank among the highest in the world. There appears to be a dichotomy between the collective economic health of the nation, and individual contentment of its people.

Surely there are lessons there. Our two worlds, it would seem, have much to learn from each other. On a personal level, I love being Canadian and am grateful for the choice my father made to immigrate to this country, as was he. I also recognize that the Italian diaspora resulted a certain natural selection process whereby the ambitious and driven were more likely to leave their familiar surroundings, and so these differences are not surprising. Nonetheless, I very much appreciate the values and family focus of my ancestral home and have come to realize that occasional inoculations of “la dolce vita” provide much needed perspective.

When Fabrizio arrived and opened, I found that the door actually rolled up so that the store completely opened to the street. It became an open-air kiosk where he did his business on the sidewalk. In fact, all the stores were similar so that the street became sort of an open- air market where proprietors, passers-by, street residents and, occasionally, customers like myself, mingled as business was conducted. It was crowded, noisy, confusing, but welcoming and very engaging. There was none of the structure and process we associate with the consumer experience but things seemed to get done. Fabrizio, once we finished introductions and after he had enquired about every detail of the upcoming wedding, was able to find exactly what I needed from among the debris that was his workplace and install it in my cellphone. He had to stop a couple of times as his children wandered down to the store with some domestic issue that always, immediately, took precedence.

The wedding, by the way, was wonderful but started a half hour after the scheduled time due to the bride’s late arrival. No one seemed surprised. No one minded – least of all me.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

 

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Discover, Examine, Commit: A New Way of Looking at Group Work

I’m back with another perspective on collaborative learning.  This time, I’m indebted to Jim Sibley at UBC for giving me permission to use Framework for TBL Application Activity Reporting Facilitation by Loretta Whitehorne, Larry Michaelsen, and Jim Sibley, reproduced here:

Our own Dr. Lindsay Davidson brought this home from the Team Based Learning (TBL) Collaborative’s Meeting this year.

or click on this:

framework for reporting

This framework is designed to help us facilitate reporting on activities in our TBLs (SGL’s for Queen’s)…The 3 stages of an activity’s progression, Discovery, Examination and Commitment are great terms for ways of looking at key steps in any activity—in other words:  get information, look carefully at the information and do stuff with it, and create a product. Specific tasks within each stage are extremely helpful advice for students and faculty to give reports on how they are doing in an activity.  They’re also very helpful prompts for actual tasks!

(Actually, for the physicians and medical students out there, you can also see the 3 stages of arriving at a diagnosis:  Gather information, Examine the information carefully and relate to experience, patterns, etc. and finally Commit to a diagnosis.)

However, these days I am focused on collaborative learning, and trying to go beyond the Norming, Storming, Reforming approach which many have often been taught.  I often hear from students, “I’m not sure what to do in the group, except report back.”

The framework that Whitehorne, Michaelsen, Sibley have developed immediately gave me ideas about roles a student could take on in a group.  In looking at the framework, I’ve grouped the 5 main roles and given them an attribute.  So following are several behaviours that students can adopt;  ideally the same person could adopt all 5 roles in one activity, depending on the group’s need.  In fact, if a person remains in one role too long, it may make the group less productive.  The idea is to recognize what is needed and move into that role to help move the group task along:

1. Sensor (Listens, shares, looks for consensus, is aware of others’ ideas)

2. Converger or Focuser (Focuses on specifics, probes, builds on others’ ideas, examines in depth)

3. Generalizer (Takes specifics to generalizations, expands, relates to frameworks or theory)

4. Summarizer and Synthesizer: (Puts it all together, supports and asks, “What if?”)

5. Maverick: (Looks for the different, the alternative, the unconventional, etc. Dare’s to differ instead of follow the crowd if it’s going “down the rabbit hole.”) Checks on things.

If you look at the Framework’s matrix, you’ll see that the Sensor’s role stays quite true throughout the different stages of an activity, as does the Summarizer-Synthesizer, etc..

Then there are great descriptions of behaviours a group member can adopt to move the group work forward based on the framework.

For example, looking at the framework, under the Discovery stage,

a Sensor can respect and listen actively to all contributions.  H/she can also be a person who moderates or facilitates so everyone gets their turn.  A Sensor can also unpack or explain in detail how a team arrived at a decision.

A person who is the Generalizer might restate the aggregated ideas of previous speakers, or link or combine, or put ideas together. S/he may articulate links between ideas or incorporate multiple sources into a single idea.

If your activity has progressed to Examining stage, the Sensor might compare or contrast by examining rationales to articulate similarities and differences.  The Maverick might redirect or park by gently guiding conversation away from non-productive directions, and refocusing to direct attention to other thematic elements.

Under the Commitment stage (and I like this term, because it symbolizes positive and concrete final steps), the person who is a Converger-Focuser may generate specific examples by applying concepts and incorporating personal experience.  The Generalizer may create general rules by drawing out the general principles and developing tentative “rules of thumb”.  The SummarizerSynthesizer may make predictions by considering what might happen as a result of particular idea in particular scenario.  What is the role of a Maverick at this late stage? Even as the group pulls together a product or a choice, or an answer, the Maverick considers to what degree the choice or answer fits into the context or the applicability.

All in all, I got very excited when I saw this framework—not only because it focuses on ways to extend tasks and activities for group work but because it adds to my thoughts on collaborative learning.  I also have to compliment the artist behind the figures in this framework (Angela Cunningham?)—they are extremely helpful when you work at grasping what the behaviours are!

So happy collaborative learning with a few more tips and strategies for our students working in groups and teams.

 

P.S. I’m also writing this on July 1…and so want to celebrate our country’s 150th with you by wishing you a Happy Canada Day!

Canada Day South Huron 2017

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Is every Canadian medical school graduate entitled to become a practicing physician?

If you’re reading beyond the title of this article, it is likely that you either believe this is already the case, or have a fairly strong opinion on the subject. In fact, I’ve come to learn that many Canadians, including medical school applicants and their families, believe that entry to medical school is the final major barrier to a career in medicine.

In the interest of ensuring a common starting point to this discussion, let’s clarify that a medical school degree does not entitle anyone to practice medicine in Canada. Graduates must also undertake and successfully complete a residency program. There are about 30 such programs available to graduates, all considered postgraduate programs within the same universities that house our medical schools, and all leading to qualification by either the Canadian College of Family Physicians or Royal College of Physicians and Surgeons.

Resident physicians, unlike medical students, are salaried during their training, which can last up to 7 years. The funding is provided by provincial governments, that therefore control the number and specialty distribution of postgraduate residency positions. In doing so, the number of medical school graduates is certainly known and considered, but the perceived societal need for physicians, both in terms of absolute numbers and specialty mix, is also a major determinant. The various ministries utilize complex but intrinsically imprecise methods to estimate those needs.

Each year, about 2900 students graduate from our 17 Canadian medical schools. There are a total of about 3300 postgraduate training positions available across Canada in all entry disciplines. In theory, there should be space available for all graduates. However, the specialty distribution of those positions does not match the career interests of the graduates. In fact, far from it. Some disciplines have many more applicants than available positions and are therefore highly competitive. Others that often fail to fill their positions. In addition, about 700 postgraduate positions are in exclusively French language environments and therefore not practically available to all graduates. Finally, each year about 2500 Canadian citizens or landed immigrants who graduated from schools outside Canada also apply for residency training positions. Although the number of positions for which they are eligible is restricted and controlled, they further reduce the availability of positions for Canadian medical school grads.

The net result of all this is that a steadily increasing number of Canadian med school grads are failing to find residency positions each year. This year, that number was 68, up from 46 in 2016 and 39 in 2015.

Depending on your particular perspective on this issue, those numbers may seem either insignificant or a major concern.

It is certainly true that the vast majority (over 97%) of Canadian graduates find residencies although not necessarily in specialties or locations of their choice. That is far more than occurs in virtually any other area of study or any other professional school, and may be seen as a reasonable concession in order to balance personal preferences against the societal need to have the right number of the right type of physicians in the right places, at least as assessed by those elected or appointed to protect the public interest. Medical education, after all, is not a right but a privilege, and a lucrative privilege at that. It is highly subsidized through the public purse, to the tune of an estimated half million dollars per physician in public funding. This is beyond the costs incurred by students themselves. It could also be rationally argued that an undergraduate medical education could serve as an excellent preparation for a variety of alternate careers, such as research, health system administration or medical technology.

Whatever your personal perspective, there are a number of consequences of this increasing phenomenon of “unmatched” graduates that must be considered.

  • The sizable societal investment in medical education noted above is clearly intended to result in a productive physician engaging the health concerns of citizens. Anything else is a misappropriation of resources.
  • The increasingly competitive environment for postgraduate positions is, understandably, becoming an increasing focus of attention to students. This influences how they engage all aspects of their curriculum and compromises what should be a time devoted only to learning and skill development. It also threatens the sense of collegiality and collaboration so important to a physician’s professional development and wellness.
  • Undergraduate medical education is designed and structured with the intention of producing practicing physicians. It is seen as a continuum of training that leads seamlessly to practice readiness. The academic and professional expectations of students are based on this assumption. If significant numbers of students do not progress in their training, that concept and educational approach will no longer be justified. Can or should such high standards be maintained if significant numbers of students are expected to consider alternative careers?
  • Students undertake considerable personal debt in supporting their medical education. The average debt in Canada is approaching $100,000, but ranges to over $250,000. This debt is supported largely by bank loans, provided on the assumption that the student will engage a career that will allow them to repay. Failure to engage postgraduate training can therefore trigger a need to repay a large loan with no means to do so. Failure to find residency training can therefore be a financial as well as personal disaster for these promising young people as they attempt to begin their careers.
  • If the ability to obtain loans become more constrained, the already acknowledged socioeconomic barriers to medical education and careers may increase, affecting already underrepresented populations.

 

Finally, there is a huge personal cost to bear for those who go unmatched. These young people, who entered the study of medicine with understandably high hopes and aspirations, are forced to face rather bitter disappointment and self-doubt, often for circumstances that neither they nor those who advise them fully understand. That reality has been evident to those of us involved in medical education for many years. Recently, this situation has taken on a public face, thanks to the willingness of the family of Robert Chu to share their personal loss.

 

The following is quoted from a letter Robert addressed to Ontario Health Minister Eric Hoskins April 18, 2016:

“Without a residency position, my degree…is effectively useless. My diligent studies of medical texts, careful practice of interview and examination skills with my patients and my student debt in excess of $100,000 on this pursuit have all been for naught.”

 

Robert took his own life in September of 2016, after two unsuccessful attempts to obtain a residency position.

 

We cannot presume Robert’s motives for his actions, nor can this tragedy be laid at the feet of any individual or institution. However, it would be equally wrong to dismiss Robert as an inevitable casualty of a flawed system. At the very least, he personalizes and therefore crystallizes this issue for us and we should not dismiss the opportunity he and his family provide to engage this issue.

And so, we return to the initial question posed in the title of this article. Are we willing to make a commitment to our students and ensure that they have the opportunity to complete the medical training they have begun, at considerable personal sacrifice? If so, then major structural changes in the postgraduate entry process will be required, involving either expansion or sequestering of entry positions for unmatched students. Such changes are far beyond what undergraduate medical programs can achieve on their own.

To not make such a commitment is a de facto acceptance of the status quo, since it is clear that the current circumstances will continue and the number of unmatched students will therefore increase. In that event, we should, at a minimum, be fully honest and transparent with our students and applicants, clarifying that admission to medical school provides no assurance of eventual entry to medical practice. We should also alter our curricular objectives and content to ensure students are prepared for alternative careers. With no clear linkage to residency and eventual practice, clinical and professional components of undergraduate education will eventually be de-emphasized and deferred to postgraduate years, likely prolonging overall training.

And so, it must be asked: When does professional training for medicine begin? At present, the presumption is that it begins at entry to an MD program. A growing number of unmatched students changes that paradigm and, with it, the pedagogical basis on which those programs are established. The consequences extend beyond the interests of the students themselves, although they would be reason enough.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Five things to do this summer: a Med Ed to-do list

This first year I worked in a post-secondary setting, I was somewhat bemused when students asked me how I was going to spend my summer – they were heading out on a three or four month “break” and assumed I was doing the same. Some had work plans, some travel, some both. Regardless, they would be away from campus and recharging their batteries, and, perhaps, expanding their perspectives in a variety of ways. I, however, would be at my desk.

Two decades and three universities later, I’m still working through much of the summer months as are many of my administration, staff, and faculty colleagues as we stagger vacations with other colleagues and other family members’ schedules.

For those of us at the School of Medicine (including our 2018 clerks!) who don’t have two or three months off this season but maybe a couple of weeks and the odd day here or there to make a long weekend – here’s my list of five things to do that are (loosely) related to medical education. (This list is best perused—and perhaps amended or augmented—while sitting on a patio with your favourite libation).

  1. Read something not related to your discipline

In the crush of academic terms, it’s easy to fall into the trap of reading for work, not for recreation. There’s always just one more journal article to be read, one more new text to review. One more thing to stay on top of. Vow to read at least one novel (or collection of short stories, or poetry) this summer. Regardless of genre, you’ll learn something of the human condition (which is at the heart of medicine and medical education) and it will refresh you, too. So, move it to the top of your To Be Read pile. Among my picks: a toss-up between finally reading at least one of the Harry Potter books, or Abraham Verghese’s Cutting for Stone. Maybe both. The Art of Adapting by Cassandra Dunn is also in the running.

  1. Binge watch a cooking show on the Food Network

Whether it’s TiVo’ed or Netflix, the ability to skip the ads is a godsend for a rainy Saturday’s binge-watching. Opt for something where you might pick up a recipe or tip or two, but pay attention to how the host explains what they’re doing. Is it conversational? Directive? Do you stay engaged? Or pick one of the competition shows (Chopped is my guilty pleasure) and check out how different judges give feedback. Some are brutal; some overly-kind without much substance. Some have thoughtful suggestions. Many adapt their critique delivery, based on the experience and competence levels of the chefs competing. How can this inform how you deliver feedback?

  1. Enlist some pals and build a sandcastle at the beach

Sandcastles are hands-on and best accomplished as a team effort. Building one requires both attention to details and a flexibility to accommodate the sand, water, and tide schedule. The plan is rarely ever 100% completed without modifications along the way. Plus, everybody gets dirty. And, at the end of the day, there’s nothing except pictures as the tide washes it away. So, a fresh slate the next day. And, we can take the lessons learned on to the next one.

  1. Hit the movie theatre to see a summer blockbuster

Enjoy the a/c and see something outrageous. Popcorn optional. Take note of if the story drags anywhere: did you get the urge to check your smart-phone (pre-movie admonishments aside). What made your attention wander? Was it an extraneous info-dump? An overly-long car chase? Just too much of something? A gap in knowledge? If you’re working on online modules for next year, take note of where the show lost you. Adapt this insight to material you create for your students.

  1. Watch some fireworks

Most of us know that fireworks were invented in China centuries ago. According to the “Fireworks University” website, this was an accident when a field kitchen cook happened to mix charcoal, sulphur and saltpeter. What a happy accident*.

There’s no great medical education insight to go with this watch fireworks suggestion: they’re just fun. And maybe that’s the insight right there.


 * (I feel obliged to stress the importance of  following all instructions for the at-home kind of fireworks and strongly urging you to show up for community fireworks shows instead. Avoid the unplanned side trip to the ER).

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Doctors, patients, ritual and showing up

Ritual is a big part of life; this is especially evident at universities at this time of year. I recently took part in the ritual of attending convocation at another university to watch my daughter receive her Bachelor of Health Sciences degree. In addition to the parental joy of seeing my daughter on stage for about six seconds of hooding and handshaking, I had the pleasure of hearing the convocation speaker, Dr. Abraham Verghese, a physician, author and professor at Stanford School of Medicine.

The importance of ritual, both in life and in particular in the doctor-patient relationship, is something Dr. Verghese is passionate about. He’s written about this, presented TED talks, and, late last month, incorporated this message into his convocation address at McMaster University.

Dr. Abraham Verghese (Screenshot from webcast)

Dr. Verghese noted that it’s possible to get your degree without attending the ceremony, but “rituals matter.” He added: “It says something about you that you believe in this ritual, that you showed up, because showing up for rituals that matter is perhaps the best advice I can give you.”

He acknowledged that he was speaking from “the vantage point of a window of practicing medicine” but hoped his message about ritual would resonate with everyone. He pointed out that the very ritual of convocation itself makes no sense in other contexts: “You’re dressed in a way that you otherwise never dress like. And I’m dressed as I rarely dress. With distinguished faculty on the stage, you marched in proceeded by a beadle carrying the mace, an instrument of battle that’s also a metaphor of power.”

“Our anthropology colleagues teach us that rituals are all about crossing a threshold,” he explained. “They represent a transformation, whether it’s a baptism, or a bar mitzvah, an inauguration, a funeral, a graduation.”

He challenged the graduates to consider what the rituals are in their lives, in their work, before sharing insight into his own understanding of ritual in his medical practice:

“If you think about the usual clinic visits, two strangers are often coming together, one person in the room will be wearing this white shamanistic outfit with tools in their pockets, and the other individual will be wearing a paper gown that no one knows how to tie or untie. The furniture in the room looks nothing like the furniture in your house or mine. The individual in the paper gown will then begin to tell the other one things that they would never tell their rabbi, or their preacher, and in my specialty of infectious disease, they will tell me things they would never tell their spouse. And then, incredibly, they will disrobe and allow touch, which in any other context in society would be assault, but the physician gets the privilege in the setting of this ritual.”

He further explained that this is not unique to any one culture. “I care for people from all kinds of ethnic groups, and I’m struck by how many different beliefs they have about illness, about disease, about treatment, but they all know about ritual,” he said. “And you put them in that room with all its setup and they know they’re about to embark in a ritual and if you do it poorly, if you just do a prod of their belly, and stick your stethoscope on the gown, they’re on to you, they can tell when you’re doing it well just as you can tell when you’re in the hands of a thoughtful barista, a good chef, a good hairdresser, a good mechanic.

“Rituals, done well, signify people who are doing their jobs well.”

Rituals can also be transformative, he said. “I learned this firsthand in the early years of the AIDS epidemic before we had any treatment,” he said, recalling a young man who he had followed for months at the clinic and who was now dying in the hospital.

“Each day I would come to his bedside and I’d visit him and I’d talk to his mother, and not knowing what else to do in this sacred hallowed space that surrounded him with his mother holding vigil, after a while, I would begin to examine him, albeit briefly. I would listen to his heart, I would percuss his lungs, feel his abdomen, feel his spleen, even though it was very unlikely I would discover anything that would change what we did,” he said.

“I engaged in this ritual out of habit, relieved that it gave me something to do, some purpose at the bedside.”

“One day, when I came by, his mother, that eternal figure there, told me that he’d not spoken or come to consciousness since the previous noon. It seemed certain that he was about to die, and in fact, he did pass away a few hours later,” Dr. Verghese continued. “But strangely, at that moment, as he heard us talking, as he heard my voice, we saw his hands begin to move. She was astonished, ‘cause she had not seen anything before. And I was astonished, and we’re wondering what is he gonna do? And we saw his skeletal fingers flutter up and then move to this wicker basket of a chest of his. And it took us a while to understand that he was fumbling with his pajama buttons. He was trying to unbutton his shirt, he was reflexively allowing me the privilege of examining him, giving me permission. I tell you, I did not decline the gift.”

“I percussed, I palpated, I listened to his heart, his lungs. I felt connected to the timeless message the physician conveys, the same message the horse and buggy doctor, riding out to towns on the western edge of Lake Ontario 150, 200 years ago, conveyed to his or her patients of that era, when there was so little to offer,” he said.

“The message is that beyond the data, beyond the evidence or lack of evidence, beyond the medicines that stop working, here I am and no matter what, I care, I will be there with you through thick and thin, I will not stop coming, I will show up.”

Dr. Verghese then spoke about emerging artificial intelligence and how it will change medicine.

“Here’s what’s not going to change, is the need for human beings to care for each other,” he said.

“We all need it in every walk of life, but especially in the care of the sick. I’m hoping that in my field, artificial intelligence will free us from some of the drudgery of medical record keeping and allow us to fulfill the Samaritan function of being a physician, to minister to those who suffer,” he added.

He exhorted the graduates to “embrace the rituals of your life, be conscious of them.”

“Be in charge and be cognizant of those human values and rituals that you want to preserve,” he added. “Remember that fluttering hand of the dying patient, I remember it every single day.”

Unlike machines, he said, “You can care, you can love, you can preserve the rituals that showcase these things. And you can show up. Always show up.”


You can watch Dr. Verghese’s full address here. It begins around 29:05.

 

 

 

 

 

 

 

 

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