Welcome to the Undergraduate Blog
New Material and a New Way to Learn: Students as Teachers on Grief.
Recently in a second year meds class, we were debriefing the experience our 2015 meds students had with their “First Patient Project.” During that debriefing class, we had relatively unique and very engaging learning experience about a serious and under-reported topic. My thanks to Dan Corazolla, Soniya Sharma, Lindsay Bowman, Aaron Wynn, Heather Johnston, and Mason Curtis, all Meds 2015 for their help with this article.
The First Patient Project is an 18 month project which begins right in September of medical students’ first year and continues until after December of their second year. Students in pairs follow a chronically ill patient, attending health care appointments and visiting with them in their home. The students also interact with community and faculty physicians and complete critical analysis reports about their learning.
This day, on April 30, we heard from six “student teachers.” Having students teach a formal session is reasonably unique in our medical school and the topic of their teaching was also reasonably unique in medical literature: How do physicians deal with grief, on the loss of a patient? How do they recover and go on…down the hall to the next ward room with another patient in it, to another clinic room, to home?
Six of our students encountered death over the program…two of our “Patient Teachers” sadly have died over the past two years. And another pair of students lost their patient as she was the spouse of one of the patients who passed away and could not continue with the program.
The six students met with a clinical faculty member to discuss the experience, and individual discussion/counseling was made available to them. But they also continued with the project by doing research on three areas: 1. How physicians help families when a family member dies 2. How physicians can help themselves when a patient dies, and 3. How medical literature and medical education literature give insight on how to bring this up in medical education.
Their research and presentations were excellent! I thought I’d share, with their permission, some of their findings:
From Soniya Sharma and Dan Corazolla, came these concepts in how physicians can help their patients deal with grief: the differences between “normal grief” and “abnormal grief”, the tasks of grieving, the family as a resource, and the role of the physician. They consulted nine current references to expand upon these concepts to their classmates and to link up with previous sessions on this topic in their first year classes.
The title of Lindsay Bowman’s and Aaron Wynn’s talk was “Wearing your heart on your jacket: Patient death and the importance of physician grief. “ They pulled from fifteen diverse sources from Military Medicine (great article on resilience-building) to Vasalius, (How to cope with disaster loss and mourning: Galen’s paper which was lost for centuries) to more traditional medical and medical education journals. One particular source I found intriguing was J. Shapiro’s article in Perspective: Does Medical Education Promote Professional Alexithymia? A Call for Attending to the Emotions of Patients and Self in Medical Training. Acad Med 2011;86:326-332.
Lindsay and Aaron taught convincingly about the factors that make patient death difficult to deal for physicians, why grief education is important and relevant to physicians and medical trainees, the current state of grief education in our curriculum and that of other medical schools and where it could and should be represented in undergraduate and postgraduate medicine.
The third partnership to teach about this topic consisted of Heather Johnson and Mason Curtis. Their teaching centred around healthy strategies for physicians in dealing with grief. Both Heather and Mason conducted surveys or interviews. Heather’s survey inquired into when and how we should teach about physician loss and grief in our curriculum. She gave practical strategies and a model on how to move through loss and grief and created a “grief curriculum” whose components could be shared with faculty as well as students.
Interestingly both Heather and Lindsey focused on an article that, in their words, “if you had to read only article on this topic,” this would be it: The inner life of physicians and the care of the seriously ill by Meier, D.E. et al in JAMA 2001, 286(23): 3007-14. I’ve just read it too and let me chime in—a very thorough and insightful article on this topic.
Mason had interviewed physicians and created a model of grief approaches from three perspectives. He also spoke movingly about how he had responded to his grandfather’s death at a time when in medical school he was learning about oncology, palliative care and the elderly.
Students in the class afterward said that it was really positive to learn this material from their classmates. The work was solid, the literature review broad, and the points very clearly and thoroughly presented with good handouts.
The students who taught were positive too…tho’ some had not been initially Some were hesitant to teach their classmates, and concerned that it would not be well received. They were really buoyed up by the great feedback from their peers and from faculty Dr. Sanfilippo and Dr. Leslie Flynn, Kathy Bowes, Program Coordinator, Erin Matthias, Program Assistant, and patients in the room.
What’s the next step? Well, the students and I can see a need for further exploration of this subject in clerkship and residency. As well, I hope the students will put together a poster about this for CCME.
My take on this aspect of the project is this: our six student teachers were excellent teachers! They were well-prepared, and had done a thorough job in finding out in different modes and in some cases ferretting out literature on a topic that seems to be localized in only a few aspects of medicine and medical education. They were clear speakers, and had great teaching points. Their slides were excellent and they had a good beginning, middle and end to their talks. They were convincing, authoritative, and had much to share. Turning some of the teaching over to students teaches those who teach, and their classmates. We already do student small group teaching in our Community Based Projects and our Nutrition Projects—maybe some large group teaching is in order?
Beyond the teaching method, the students taught us all about a part of medicine that appears to be kept somewhat quiet. About the culture of a “stiff upper lip” that could pervade in some medical cultures. About how may physicians act differently about their own grief than they would advise a patient to act. They gave us all a lesson in how to cope in a healthy way, when you have to move on…to the next patient, the next room, the next door and all the way home.
Are you interested in the reference lists from the students? Or would you like to contact them to find out more about their talk and what surprised them? Write back here, or write to them via email addresses on MEdTech.
Curricular Leaders’ Retreat
On June 3, from 8:15-2:00, Curricular Leaders will gather for a retreat in the new Medical Building. The retreat will feature updates by Dr. Tony Sanfilippo as a “State of the Union” or report card on UGME. As well, mini-workshops on strategies in teaching and assessment will be offered. Finally updates on innovations over the past academic year and on accreditation will be offered.
Course and Unit Directors are generally the target audience of these retreats. Course Directors are invited to bring a colleague with interest in the direction of their course.
Announcements with information about the agenda, RSVP process, and location is forthcoming.
Should Every Doctor be Able to Deliver a Baby?
To many, the answer to this question may seem obvious. For those who feel an emphatic “yes” is called for, let me pose a scenario for your consideration. Imagine an airline flight about 3 hours from destination. A call goes out for someone who might assist a young woman who’s gone into premature labour. Two people respond. One is a mid career physician who underwent standard obstetrical training during medical school, delivering about 50 babies during that time, but subsequently trained as an Ophthalmologist and has had no obstetrical experience in the past 20 years. The second is a registered nurse who graduated about 10 years ago and works in a busy hospital, mostly in the emergency department, but with frequent “float” shifts in Labour and Delivery. Based on this scenario:
Who is more capable of providing competent care to the patient?
Who will most people aboard the plane (including the patient) assume is most qualified?
The point of this scenario and these questions is not to suggest some simmering interprofessional conflict. One would expect that these two professionals would recognize each other’s strengths and work together for the benefit of the patient. The point of this story, which could involve any subspecialty not involved in obstetrical care, is to highlight how much medical practice has evolved, and to suggest that our approach to medical education may not be keeping pace. This point is made even more apparent by imagining a similar scenario playing out 50 or so years ago when there was much less specialization, the practice patterns of all physicians was much more homogeneous, and physicians were fully qualified to practice at the end of medical school.
My colleague Richard VanWylick is a pediatrician and curricular leader. He and I have established a running joke regarding the toddler assessment in medical school. The examination of small children, like the ability to deliver a baby, is an aspect of medical practice that will be ultimately provided by a distinct minority of our medical class. Further, those who do provide those services in their career will undertake considerable further postgraduate training before doing so.
So, one must ask, why do we devote so much curricular time and resources to these components of medical practice? I would suggest there are a number of valid justifications:
- It’s important that our students experience all aspects of medical practice in order to make valid career decisions
- An appreciation of these areas of practice provides insights and awareness that makes us all better Doctors, and better able to understand the needs of our patients, regardless of their presenting problem or our area of interest. When I consult on cardiac issues during pregnancy, for example, it’s important to have had a practical understanding of the principles of labour and delivery.
- There exists a societal expectation that all doctors should be able to provide a minimal level of service, particularly in emergency situations. That “minimum level”, it must be said, is completely undefined.
- Our students very much appreciate the opportunity to experience all aspects of medical practice, and expect the opportunity to do so
On a purely pragmatic note, medical schools are required to provide a comprehensive exposure in order to achieve accreditation status in Canada and the United States. To quote from “Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree” (the bible of accreditation):
ED-15. The curriculum of a medical education program must prepare students to enter any field of graduate medical education and include content and clinical experiences related to each phase of the human life cycle that will prepare students to recognize wellness, determinants of health, and opportunities for health promotion; recognize and interpret symptoms and signs of disease; develop differential diagnoses and treatment plans; and assist patients in addressing health- related issues involving all organ systems.
Although schools are expected to define for themselves what constitutes adequate preparation “to enter any field of graduate medical education”, I think any program would be hard pressed to exclude active participation in basic obstetrical care and child assessments as components of that preparatory process.
However (and this is a big “however”), with the massive increase in knowledge and emergence of over 60 recognized specialties, medical education is becoming increasingly expansive and expensive. More and more, medical schools are required to make choices regarding what components of education are relevant to every physician, regardless of what specialty they chose to practice. Such decisions are being made in isolation since we lack any accepted framework or value assumptions that would support such decisions.
But (and this is a big “but”), things are changing. Leadership organizations such as the Association of Faculties of Medicine of Canada, Royal College of Physician and Surgeons, College of Family Physicians and Medical Council of Canada, are all acknowledging the need to recognize more explicitly the continuum of education from medical school entry through to full qualification. The Future of Medical Education in Canada initiative is calling for sweeping reform, including the recommendation to “Ensure Effective Integration and Transitions along the Educational Continuum”. Three committees have recently been established to develop strategies to implement this key recommendation. These groups are just beginning to grapple with some very difficult and discomfiting questions, such as:
What knowledge, skills, approaches are common and essential to all physicians, regardless of specialty?
How should physicians progress through training, and when should various training streams begin to diverge?
How should the number of specialty training opportunities be determined, and how should learners be selected for those specialties?
When should medical students be expected to declare their area of interest, and what, if any, provision should be made for those who wish to transition between specialties?
These issues will require considerable thought and reflection by all involved in medical practice, including students, postgraduate learners and teaching faculty. All involved should feel free to contribute to this dialogue, which has the potential to reform our educational systems in rather profound ways, hopefully leading to a much more aligned, efficient and relevant process. As a co-chair of one of those implementation groups, I would certainly welcome input on these issues. In the meantime, I will continue to hope to be sitting next to an experienced ER nurse if someone goes into labour during a future flight.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
How could I have forgotten Medical Humanities?
I arrived to the CCME amidst a huge storm on Saturday at 4:30 and immediately went off to a presentation and discussion with other Ed. Developers and new faculty in med ed. So I missed the Medical/Health Humanities Creating Spaces III symposium which had just wrapped up. However, our own Jackie Duffin did not miss it–in fact she was part of a panel on Medical Humanities to wrap up the Symposium, Medical Humanities: Whence and Whither? As well, meds students Emily Swinkin (2014) and Renee Pang (2013) presented — and a recent grad Jennifer Baxter (2012) — was attending just to listen from her family med residency in Chiliwack BC. To see more about this important initiative which I was able to attend and enjoy last year, go to http://medhealthhumanities.ca/Programme_Presentations.html
Why go to conferences?
Why go to conferences… In which Sheila Pinchin offers a purely personal viewpoint of the CCME Conference (13) .
Well, here I am at the Canadian Conference on Medical Education (CCME) in Quebec City, along with a great number of faculty from Queen’s, 15 meds students from Queen’s (some came up to volunteer!) Matt Simpson, Lynel Jackson from MEdTech and Andrew dos Santos from IT. As well, many staff are here (Kathy Bowes, and Jen Saunders), and our faithful Educational Team members, Eleni Katsoulas and Theresa Suart are here, too. Dean Richard Reznick, Associate Dean Tony Sanfilippo, Vice Dean Leslie Flynn, Associate Dean Ross Walker and Associate Dean Karen Smith are here. Suzanne Maranda, our head of Bracken Library is also here. And now I’m going to stop naming people as I know I’ll miss some. But these are just some of the people I’ve seen in the past day or two!
On the train up to Quebec City, we got a lot of work done, with people dropping by and talking about ideas and challenges. Dr. Sue Moffatt and we managed to squeeze in an entire planning session for the next Course Directors’ Retreat! We think the train back will offer a similar opportunity—all of us together for seven odd hours. This is a consultant’s dream: Captive faculty all in one space! ☺
I enjoy this conference so much! When I first started in Medical Education 7 years ago, I was one of the few, if not the only, Educational Developer at the conference. Now there are many more of us, and several Educational Researchers too. I don’t feel as odd, and I also feel more at home with all the faculty that come. And when you mix Ed Devs, clinical faculty, technologists and health education librarians together as we did in the workshop Lindsay Davidson, Lynel Jackson and I gave, you get powerful results! Flipped learning has never been so creative–thanks to Lynel’s wonderful graphics, and Lindsay’s really ingenious puzzle pieces activity!
Networking is happening with our faculty here—Tony Sanfilippo and Hugh MacDonald got together with their counterparts from across the country, as did Andrea Winthrop and countless others who were in interest groups and business meetings. Many other faculty were involved in formal meetings and symposia.
But informal networking has happened at mealtime breaks, and at other times, when you could see two or more heads bowed over computers or papers in the lobby and other places where you could sit. Memorably several people were sitting on the floor near the buffets– the better to be connected—to the electrical plugs in the wall and to each other, I presume.
In addition to networking, our Ed Team members (Eleni Katsoulas, Theresa Suart and I) also roam the poster aisles (we greedily snap up the mini versions), chat with people at the booths (hello CMPA Good Practice Modules, and MedicAlert Bracelet Free Curriculum!), and divide up and conquer when it comes to attending moderated poster, oral and workshop sessions. That means we’re synthesizing all this knowledge and bringing it home for everyone here—and do we have some terrific ideas!
I can’t forget to mention the White Coat Warm heART exhibit showcasing student and faculty artwork and a place of peace and provocation in a bustling conference. Here’s a shot of Dr. Carol Ann Courneya from UBC who’s been running the art exhibit since 2010 (with thanks to Dr. Ali L. Jalali for this photo from Twitter)
Kudos to the many Queen’s faculty, staff and students who gave oral presentations, poster presentations and workshops! One reason we come to conferences is to celebrate this scholarship and efforts of our educational community.
So it’s a real pleasure to celebrate and congratulate Paxton Bach, Meds 2013, on being awarded the Sandra Banner Student Award for Leadership. This prestigious award from the Canadian Resident Matching Service (CaRMS), consists of up to $5,000 annually to be given to a medical student or resident who demonstrates an interest in or an aptitude for leadership among their peers. Congratulations Paxton!
And here, Kathy Bowes and I are standing in front of our poster (with Tony Sanfilippo) about the First Patient Program telling the world (well some of it) that Queen’s is the first Canadian medical school to bring this kind of longitudinal learning from patients to years 1 and 2 students in medical education. This was a great idea Tony Sanfilippo brought back from an AAMC conference two years ago. I wonder what great ideas he’ll be bringing back from this conference!
Eve Purdy, Meds 2015, wrote this for our UG blog:
“For me the highlight was the huge social media at the conference allowing for faculty and students across the country to engage whether or not they could make it to Quebec City. It became evident that the efforts of Queen’s students and faculty to model online professionalism are significant and unique. We’re among those leading the charge! This blog is great evidence of those efforts. Having the opportunity to interact with online mentors, people from all over the country having significant impact on my medical education, in real life was well worth the trip (Dr. Jalali, Dr. Yiu and Deirdre Bonnycastle to name a few)!”
Here is a sample of faculty from U of T and Ottawa U tweets to Eve.
For stats on Social Media use at the conference see:
Ben Frid, also Meds 2015 and Aesculapian Society President, wrote this for us:
“Here is a photo of the Queen’s CFMS delegates, all of whom stayed in Quebec City an extra day and a half to attend the first part of CCME and the Dean’s reception.”
Ben continues, “One highlight for me was a fascinating presentation on Hidden Curriculum by a PGY-4 from McGill. She was exploring factors and common experiences amongst clerks that lead to hostile learning environments. She was very clearly advocating for medical students and progressive medical education, and it was inspiring to see another resident speak up at the end of the talk to lend his full support as well. I think residents are in a uniquely favourable position to mediate and collaborate between medical students and attending physicians and it was terrific to see these residents take up this important cause.
Another highlight was the Dean’s reception last night. It’s always fun to interact with faculty in an informal setting, and when I looked around the room I saw a mix of students, faculty, administrative staff, and alumni all enjoying each other in lively conversation — a shining example of Queen’s collegiality! Queen’s pride was abounding and amidst the Queen’s tartans and flags, I’m quite sure I saw the classic Queen’s pin on every lapel in the room. I had the chance to shake hands and share stories with John Ruedy, Aesculapian Society President in 1955, who has spent his time since then making incredible strides in transforming clinical and academic medicine across Canada. A very neat experience indeed!”
Theresa Suart, our new Educational Developer, who used her journalist’s background to ferret out literally every learning opportunity, says, “What’s really amazing is how so many people are working so hard to educate our future physicians! The energy is amazing and very inspiring.” Eleni Katsoulas, our new Assessment and Evaluation Consultant, who attended eighteen oral sessions, nine moderated poster debriefs, and one workshop, all on assessment, says she learned a lot. “But what sticks out in my mind is how important and energizing the networking is—so many helpful and collaborative people!”
I entitled this blog, “Why go to conferences?” They are a lot of hard work, a lot of travel, long hours, and a lot of time away from home, family and work.
But they also mean a great deal of learning about the best and latest in our fields, great ideas for helping our students, the ability to peer forward into the future, new people to connect and work with, a chance to do some thinking, a chance to drink in knowledge, and a chance to celebrate scholarship from our own institution as well as inhale that from others.
Don’t take my word for this! Go into Twitter and see the scope of the learning that went on at #CCME13.
Next CCME is in Ottawa—see you there!
My thanks to Eve Purdy for most of the photos and the comments, Ben Frid for the CFMS Delegates’ photo and comments, Dr. Jalali for the twitter photo of Dr. Courneya and her poster, Theresa Suart and Eleni Katsoulas for the company and the great quotes, and Dr. Sanfilippo for sending us here!
Do you have any CCME 13 experiences to share? Post them here!
Reflecting on Reflection
Reflection in Medical Education
I love those who can smile in trouble, who can gather strength from distress, and grow brave by reflection.–Leonardo da Vinci
I thought I’d write to you about reflection in this blog entry. I can hear the meds students groaning already:) You see, we ask the meds students to do a fair bit of reflection in undergraduate medical education, starting with term 1 when we ask them to reflect on being a physician, and on through to their last portfolio assignment in pre-clerkship when we ask them to reflect on how well they have progressed in their learning about the roles of a physician.
Reflect is a rather over-used and under-thought term and so as I progress through this, you may want to substitute another term. I happen to like “critical analysis” because a lot of reflection should include that, and a lot of what we’re asking the meds students to do includes critical thinking.
When we talk to the medical students we talk to them about the stages of reflection and we use one model of reflection for learning or “reflection in and on action” (Schon, 1983), that of experiential learning by David A. Kolb. Kolb (with Roger Fry) is well-known for his conceptualization of reflection as a critical part of learning (Kolb, 1984). He postulates a cycle of reflection where a learner experiences something concrete (Concrete Experience), observes and reflects upon it (Observation and Reflection), generalizes the learning in Abstract Conceptualization and then applies the learning to new experiences in Active Experimentation. This starts the cycle again, with a spiral approach so that one is not repeating the same learning over and over. Kolb also notes that one can enter the cycle at any stage in the 4 steps.
When we present to the meds students we use this graphic:
To me this theory is important as it allows for some very practical outcomes for reflection. As Peter Drucker says, “Follow effective action with quiet reflection. From the quiet reflection will come even more effective action.” Two leaders in the field agree: Dr. John Sandars defines reflection as “A metacognitive practice that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters.” (Sandars, 2009) Jack Mezirow when writing about “transformative learning” describes reflection as critical awareness of how we are constrained, and how to reformulate so as to act. (Mezirow, 1997)
So how can we assist learners to reflect in order to change their actions? How can we promote “rigourous reflection?”
Dr. Ted Ashbury and I start by asking them to jot down some thinking: “Think of a situation where you have said, “I’m not going to fall into that trap again. I’ve thought about this, and I know I’m prone to…”! We show them the cartoon of Charlie Brown and Lucy and the infamous football… This is helpful because one goal of reflection can be to change action, to break a cycle or pattern.
Next, we ask the students to think about a situation that has engaged their attention in the past few weeks and fill in a chart based on the 4 steps in Kolb’s theoretical framework:
||Analyze:Make connections Prior experience
Links to knowledge of yourself
|Apply/Plan (Now What?)Changes or shiftsCommitment to future action/plans|
And we ask them to set some goals: SMART Goals
Specific (straightforward, not ambiguous)
Measurable (It is clear under which conditions the goals are achieved)
Acceptable (The goals should be acceptable to all stakeholders)
Realistic (The learner should be able to achieve the goals)
Time-bound (It should be clear when the goal is to be achieved)
Free Writing: We give students time to write—free writing for at least 5 minutes (an engaging and difficult task—I recommend it!) about the prompt from the beginning of the session or “Write about your First Patient Experience, your Clinical Skills experience, your learning elsewhere in term 1, a key challenge you have chosen to work on recently, Mid-terms…???” We also offer them a reflection written by a student in another meds school and a rubric that Eleni Katsoulas and I designed to help us and them assess reflective writing. They get to analyze their colleague’s writing based on the rubric:
|Prompt or Catalyst||Ideas (What?)||Connections (So what?)||Extensions (Now what?)|
|Observed behaviours of other||Describes the behavior and the context in which it occurred||-Interprets the behavior, its cause, or provides a rationale (impact)-Seeks out primary resources/information/circumstances, to connect to and make sense of the observation||– Provides an alternative to problematic behavior based on consideration of all primary observations-Discusses implications and considers how or whether to implement change in their own behaviour-Problem may be reframed, and there is an explanation of how this represents a change from previously held beliefs
-Considers impact of framework on behavior (culture, system, etc.)
-Commits to future action, reflection, or advocacy
This seems like a lot of work to accomplish reflection, doesn’t it? However, it’s like learning skills for anything…we provide opportunities to break down the skill into discrete parts, and learners time to practice. The idea is that the more they practice this, the more intuitive and natural it becomes. This doesn’t negate the possibility and importance of a 30 second reflection on an interesting, provocative, or disturbing matter, but it does lead, we hope to rigourous reflection.
I thought I’d finish this section with a quotation from a medical student who was reflecting:
“If I had to choose what I felt to be the most important thing that I have taken from these experiences, it would be to remind myself, no matter how I feel, to think about how the patient is feeling. To never forget that off-hand comments made when tired or stressed have the potential to upset people to such an extent that they remember them for years.” (Macauley & Winyard, 2012).
If this is the result of rigourous reflecting, I’m all for it!
What are your thoughts on reflection in medical education? What use do you see for it? (or do you see a use?) What strategies do you recommend? In the next blog, I’ll send some tips for reflection, along with your suggestions.
Kolb, D. A. (1984) Experiential Learning, Englewood Cliffs, NJ.: Prentice Hall.
Kolb. D. A. and Fry, R. (1975) ‘Toward an applied theory of experiential learning;, in C. Cooper (ed.) Theories of Group Process, London: John Wiley.
Schön, D. (1983) The Reflective Practitioner, New York: Basic Books
Saunders, John. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685-95.
Mezirow, Jack. (1997). Transformative Learning: Theory to Practice. New Directions for Adult and Continuing Education, 74, 5–12.
Macauley, CP & Winyard, PJ. (2012). Reflection: tick box exercise or learning for all? BMJ Careers. http://careers.bmj.com/careers/advice/view-article.html?id=20009702
Basic Science in Medical School. Too much? Too Little?
In his 1988 book “All I Really Need to Know I Learned in Kindergarten”, Robert Fulghum takes a tongue-in-cheek approach to education. His intuitively attractive postulate is that early learning is the most durable we will experience, and those fundamental lessons and principles, well established early in life, can be the most valuable contributors to lifelong learning.
I found myself thinking about this recently after reading a “state-of-the-art” article in the Journal of the American College of Cardiology entitled “Pathogenesis of Acute Coronary Syndromes” (Crea F, Liuzzo G, JACC 2013;61:1-11). The authors provide a contemporary review of the pathophysiologic underpinnings of ACS, describing a complex interplay of structural, inflammatory, metabolic, hematologic and genetic factors that can be at play and can lead to the various clinical presentations we recognize.
Over the years that I’ve been in practice, the understanding of what causes ACS has evolved in a steady and very gratifying manner. In medical school, the concept of myocardial ischemia my classmates and I engaged was encapsulated by a famous Frank Netter drawing of a businessman with a briefcase clutching his chest leaving a restaurant (presumably having enjoyed a large meal) on a cold day. In retrospect, it’s easy to dismiss that image as a rather quaint and simplistic model of what turns out to be a rather complex process.
However, when I think about the fundamental science that underlies the current mechanisms developed in Crea and Liuzzo’s article, I realize how many of those key concepts were first, and very accurately, developed within basic science courses we undertook in our first year. Concepts such as:
• the structure and histology of coronary arteries
• the inflammatory response
• platelet aggregation and thrombosis
• arterial vasospasm
• genetic predisposition to disease
• lipid metabolism
• sympathetic responses to exertion and emotional stress
These topics, esoteric in isolation, have a few, very interesting things in common.
• They are all necessary to understanding current concepts of ACS
• Knowing something about them allows me to appreciate (and even enjoy reading about) contemporary approaches as outlined in the JACC article.
• They were all part of my medical school experience 35 years ago
While I was struggling to learn those concepts, I had no idea they would ever have practical impact on my practice. In fact, my classmates and I were of the very strong opinion that learning these concepts was a decided waste of time that could be better spent seeing patients and learning the “nuts and bolts” of clinical medicine.
Today, undergraduate curriculum committees, including ours, continually struggle with the questions “what should we be teaching” and “what will they need to know”. The desire to ensure the scientific foundations are appropriately presented has to be balanced against current trends to provide more “patient-centred” content, to provide “clinically relevant” content, to ensure our students are introduced to the ever-expanding compendium of clinical knowledge and therapeutics.
But are these forces really at odds? Do we really need to choose between what’s “science” and “clinical”? We don’t, as long as we’re willing to consider new approaches to education. The answer to this apparent dilemma lies in development of integrated learning that doesn’t segregate and marginalize the “science”, but brings it front and centre, linked appropriately and logically to the clinical contexts in which they’re utilized.
Within the next few weeks and months, Dr. Michelle Gibson, Year 1 Director, and Dr. Chris Ward, Course Director for Normal Human Function, are leading a comprehensive review of our objectives in Basic Science. It’s become clear after five years of application that the current framework outlined in our “red book” (Curricular Goals and Competency-based Objectives) merits review and likely revision. In doing so, they will be engaging the faculty at large and will welcome your contributions.
So, do I believe I learned everything I really needed to know in medical school? No. But I certainly didn’t appreciate at the time how useful that learning would prove to be.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Flipped Learning: “Turning learning on its head”
Here’s a scenario of an innovative educational method that is sweeping through the halls of academia: Imagine…students are hard at work at home accessing captured lectures, PowerPoint slides, audio or video casts, reference books, or other resources to learn about foundational factual material. They then go to class to spend the teaching/learning time on applied cases, projects, or problems where they can question the teacher, and work with their classmates on solutions and discoveries. Sound familiar? This is an example of “Flipped Learning”. I’d like to show you that we at Queen’s Meds are way ahead of the curve—we’re practicing “flipped learning” in “flipped classrooms already!”
A brief history of the Flip:
In 2000, J.W. Baker presented on a “Classroom Flip” where he used technology to allow students to read and learn at home, and became the “guide on the side” for them in class.
Formally defined in the literature by Lage, Platt and Treglia (2000) as the “Inverted Classroom”, the authors, from the Economics Department at Miami University, outlined a multimedia strategy for teaching that “appeals to a broad range of learning styles, without violating the constraints faced by instructors at most institutions.” (p. 31). By inverting the teaching and learning that took place inside and outside their economics classroom, the teachers gained more time to address diverse learning styles and challenges. They allowed groups and individual students to do their “homework” in the classroom, and reserved traditional lectures for outside the classroom.
In 2007, two high school chemistry teachers, Bergmann and Sams, recorded their PowerPoint lecture presentations using then newly developed screen capture software. Bergmann and Sams had built the videos for absent students to catch up, but found that students who had been present accessed the material to study and review. This left them time to spend in a classroom, on inquiry, and “deeper learning.” According to Bergmann, the Flipped Classroom “took off like a rocket!” (Bergmann, 2012.)
In March 2011, at Ted Talk, Salman Khan, spoke about flipping the homework/lecture equation. A hedge fund manager with multiple degrees in math and science from MIT Khan created the Khan Academy (www.khanacademy.org/), from his original math tutorials for his niece, to a very successful and free source of over 2,600 online tutorials covering everything from math, chemistry and even medicine. (Kahn, 2011). “Khan asserts that teachers in a traditional classroom spend five percent of their time actually working with students, while spending the other 95 percent lecturing, creating lectures or grading. Using Khan’s free online math tutorials, teachers flipped this equation, using technology to “humanize the classroom.” (Huston and Lin, 2012).
The growth in acceptance of this method is evidenced by, among many things, the best selling Bergman and Sams (2012) ISTE publication “Flip Your Classroom: Reach Every Student in Every Class Every Day.”
So, that’s what the “flip” is all about. What are we doing here in Queen’s Meds and what are some of the challenges we have to overcome in our use of “flipping”?
If you’re teaching in Undergraduate Medical Education (UGME), chances are you’ve come across our “SGL’s” or “Small Group Learning” sessions. With Dr. Lindsay Davidson’s example to guide us, we in UGME have adapted Team Based Learning (TBL) for these sessions. Here, we provide students with what had previously been the purview of the lecture: foundational facts through readings or other resources, from textbook chapters with reading guides, to online modules, complete with interactive quizzes, videos, etc. Students are provided with some “homework” time in our Directed Independent Learning sessions and are expected to come to class prepared to engage in inquiry through group work, with cases, or problems where they can apply their learning. The faculty member, often with a colleague, (other faculty, residents or fellows), facilitates the session, but notes that if he/she is talking more than 25% of the time, he/she is straying into the other side of the flip and not focusing on the student learning.
Why did we do this? For the same reasons that the flipped classroom is reaching so many teachers and students.
Here’s what Jon Bergmann has to say about this type of learning:
- Flipped Learning transfers the ownership of the learning to the students.
- Flipped Learning personalizes learning for all students
- Flipped Learning gives teachers time to explore deeper learning opportunities and pedagogies with their students (PBL, CBL, UDL, Mastery, Inquiry, etc)
- Flipped Learning makes learning (not teaching) the center of the classroom.
- Flipped Learning maximizes the face to face time in the classroom. (Bermann, 2012)
Now, what are some of the challenges? And how can we address them?
- It’s important that the students have prepared before coming to class. We do this by a. appealing to students’ sense of responsibility and professionalism, b. appealing to students’ common educational sense (they have to prepare if they are going to work on the applications) c. tying the preparation to assessment and grades into the preparation, d. using Readiness Assessment Process (lovingly known as RATs) which allow for enhanced group learning of concepts.
- Flipped Classrooms came about through innovations in technology that allowed for Lecture Capture, Narrated PowerPoint, and other technological tools. The key is not to get carried away with the technology but focus on the value of what is being offered to students: on guiding them through the learning and then inextricably weaving it with what is going to happen in class. One indispensible factor is quality: the captured lecture, online module, or even textbook chapter must have been carefully selected and/or crafted the way any good teaching tool would be.
- There really isn’t anything revolutionary about a video lecture. A recorded lecture is still just a lecture. What’s critical here is guiding of the learning. We are advocating Reading Guides for chapters or articles, quizzes and interactive questions for online modules, and short (5 minute) captured lecture bursts to guide readings, etc. Can the students learn from a captured lecture? Yes. Can they learn better with additional or with other tools? Absolutely. Bergmann cautions that flipped learning is NOT “a synonym for online videos. When most people hear about the flipped class all they think about are the videos. It is the interaction and the meaningful learning activities that occur during the face-to-face time that is most important.”(Bergmann et al, 2011.)
- Are lectures “bad”? Absolutely not! Flipping makes room for another teaching method, or several of them. But lectures have a place in medical education, especially for introducing a concept, generating excitement in a topic, providing a framework for learning, and other suitable purposes.
- It’s still about what happens in the classroom. I used the word “inextricably” above—the independent student learning must be closely linked to what happens in class. The class time is used to check on the student learning, clear up any questions, and work through well-thought-out and well-crafted group activities. Student intra-group discussion, student inquiry, students debriefing to the whole class, and instructors providing feedback to students about their learning are important activities. There is still a lot for an instructor to do in helping students to learn; it’s just been “flipped.”
Do you have questions or comments about “flipping”? Write back to the blog.
Baker, J.W. (2000). The Classroom Flip’: Using Web Course Management Tools to Become the Guide by the Side. Selected Papers from the 11th International Conference on College Teaching and Learning (11th, Jacksonville, Florida, April 12-15, 2000). Chambers, J.A., ed.
Bergmann, J. (2011). The history of the flipped class: How the flipped class was born [Web log post]. Retrieved March 24, 2013, from http://blendedclassroom.blogspot.com/
Bergmann, J. (2012). The Flipped Class as a Way TO the Answers. Flipped Learning. Retrieved March 24, 2013 from http://flipped-learning.com/
Bergmann, J. (2012). Flip your classroom : reach every student in every class every day. Eugene, Or. Alexandria, Va: International Society for Technology in Education ASCD.
Bergmann, J., Overmyer, J. & Willie, B. (2011). The Flipped Class:
What it is and What it is Not. Retrieved March 24, 2013 from http://www.thedailyriff.com/articles/the-flipped-class-conversation-689.php
Houston, M. & Lin, L. (2012). Humanizing the Classroom by Flipping the Homework versus Lecture Equation. In P. Resta (Ed.), Proceedings of Society for Information Technology & Teacher Education International Conference 2012 (pp. 1177-1182). Chesapeake, VA: AACE. Retrieved from http://www.editlib.org/p/39738.
Kahn, S. (2011). Let’s use video to reinvent education. Speech presented at TED2011. Retrieved March 24, 2013, from http://www.ted.com/talks/salman_khan_let_s_use_video_to_reinvent_education.html
Lage, M.J., Platt, G. J., Treglia, M. (2000). Inverting the classroom: a gateway to creating an inclusive learning environment. Journal of Economic Education.
Team Based Learning Collaborative. Getting Started. . Retrieved March 24, 2013 from http://www.teambasedlearning.org/starting.
Thompson, C. (2011, August.). How Khan Academy Is Changing the Rules of Education. Wired. Last retrieved on March 24, 2013 from http://www.wired.com/magazine/2011/07/ff_khan/
Zappe, S., Leicht, R., Messner, J., Litzinger, T., Lee, H., (2009). “Flipping” the Classroom to Explore Active Learning in a Large Undergraduate Course. American Society for Engineering Education.
Medical School Admissions: Unintended Consequences
The response to my last article on the topic of medical school admissions would suggest that there’s both interest and concern regarding our current processes. In addition to the very interesting responses that were posted, a number of practicing physicians and students communicated with me directly with similar insights. It seems clear from this feedback, and from our own experiences here at Queen’s, that the combination of high demand for medical school positions and the “ill-designed tools” I alluded to in the previous article is giving rise to consequences that are at least unintended and, in the worst case, undesirable. Examples of those unintended consequences:
Strategic selection of undergraduate courses and programs. Academic Records have always been the cornerstone of the admission process. However, lack of uniformity regarding course content and evaluation rigour between institutions (and even departments in the same institutions) has eroded their reliability. It’s widely appreciated that some universities and programs take pride in the demands they place on their students and the meaning of an honours grade. Students attending such institutions therefore put themselves at a competitive disadvantage, despite receiving what all would agree is an excellent educational experience. In addition some disciplines, such as English and the Humanities, rarely award marks above the mid 80’s. Postgraduate science courses tend to award higher marks than undergraduate courses in the same discipline. Although all these vagaries are widely appreciated, there is no acceptable or fair means to equilibrate these inequities. Consequently, students interested in pursuing medical school admission may be making choices based on strategic priorities rather than interest or natural aptitude.
Resume construction. Applicants perceive a need to ensure their non-academic resumes reflect interest in medical and humanitarian pursuits. Although such efforts are obviously laudable, they may be chosen for strategic rather than purely altruistic value, and come with the price of exclusion from other very healthy growth experiences. In addition, such experiences may not be equally available to applicants from diverse communities and socioeconomic backgrounds.
Commercialization of Medical Education. The large number of young people seeking admission to medical school have become an economic “market” and medical education has become a “commodity”. The $270 cost of writing the MCAT does not seem unreasonable, but must be coupled with the cost of preparatory material, preparation courses, travel to and from examination sites, and multiple examinations that many candidates undertake in order to ensure competitive results. University undergraduate courses in biologic sciences have increasingly taken on a distinctly “medical school prep” tone, to the point that program designations have evolved to terms that denote closer links to medical education (“health science”, “medical sciences”), even providing MCAT preparation as part of the curriculum and publishing statistics regarding the rate of medical school acceptance among enrolled students. Although such programs may be of intrinsic value, one wonders whether there is sufficient value and career opportunity for the majority of participants who will not be successful in their medical school applications. Finally, the steadily increasing number of international medical schools that are offering positions to students able to bear the financial burden and accept the uncertainties of postgraduate placement is a clear consequence of the mismatch between demand and positions in Canada.
Premature exclusion (or selection) of Medicine as a career option. Admission to medical schools is increasingly seen as the ultimate award for academic excellence. There is an emerging perception that only academically very successful students need apply and, conversely, that high academic success carries the expectation of medical school admission, almost as an earned right. Both perceptions are problematic. The former excludes (or at least fails to encourage) students on the basis of very early and likely unrepresentative academic experiences. The latter runs the risk that students will set themselves, and parental expectations, on a very determined career path with an incomplete understanding of the demands of that career or their own suitability.
Socioeconomic barriers. Many of the factors noted result in significant barriers to less economically advantaged members of our society. A 2002 analysis of medical school enrolments revealed that only 10.8% of first year students came from rural areas, despite the fact that 22.4% of Canadians live in rural settings (CMAJ 2002; 166: 1029-35). The same study showed that 17% of medical students came from families with household incomes over $160,000, although only 2.7% of Canadian households had incomes over $150,000. Conversely, 15.4% of medical student families had household incomes less than $40,000 in 2002, although 39.7% of Canadian households are in this range. Although such observations do not allow us to conclude that a “barrier” exists, it does appear that our students are drawn from the socioeconomically advantaged sectors of our society, and some of the observations noted above provide explanations for this trend.
I ended my previous blog article by posing the question “Do we have a problem?” Most of the respondents felt we do, based on the issues noted above, all of which suggest the system is neither fully accessible to all deserving applicants, nor fundamentally aligned with the values our society would expect of the medical profession. However, no one seems to question the integrity of the process, nor the quality of the students who are ultimately being selected to medical school. We’re therefore left with the much more difficult issue, specifically: What, if anything, are we prepared to do about it?
There would seem to be two potential options:
- Try to change the admissions system to correct or modify the various issues, or
- Expand the number of medical school positions to admit more applicants
Both are obviously quite complex and far-reaching. The first option would require directed approaches to each of the issues listed above. For each, strategies could be developed and, in many cases, have been implemented with some success. Examples of such strategies could include any or all of the following:
- Adjustment of undergraduate grades to account for university or program “degree of difficulty”
- Development of a more valid and aligned standard entrance examination
- Greater scrutiny regarding the content and impact of non-academic experiences
- More scrutiny regarding the content and outcomes of undergraduate programs
- Development of more aligned pre-medical undergraduate experiences, perhaps linked to medical school admission
- Provision of economic support to socioeconomically disadvantaged students seeking medical education
- Stronger links with high school programs to ensure students are aware of the expectations of medical education and practice
- Linkage of medical school admission with specific service requirements
These and many other options are controversial, highly complex to implement and individually incomplete solutions to the problems we’ve identified. In addition, we would be left with the fundamental issue of still not having enough places for what would be a slightly different, but no smaller applicant pool.
The second approach (increasing medical school positions) has, in Canada, been linked to considerations of physician supply. As thoughtfully reviewed recently by my friend and colleague Dr. Steven Archer, new Head of Medicine at Queen’s (http://deptmed.queensu.ca/blog/?p=266) and also by Dr. Reznick, Dean of Health Sciences (http://meds.queensu.ca/blog/?p=2072), this is a highly complex issue, with no clear data and considerable controversy currently swirling as to questions as fundamental as whether Canada is under or over-supplied with physicians. However, we might engage this issue somewhat differently if we reflect on two realities of modern medical education:
1. The MD degree historically designated readiness to engage medical practice. This has not been the case for at least 50 years. Although our MD programs all provide fundamental clinical training and experience, it is with the intention that students will transition to more intense and direct clinical involvement in their specialty based postgraduate years. In fact, graduates now require a minimum of two (and often up to 7) additional years of postgraduate training, predominantly based in clinical settings.
2. The major limitation to expanding undergraduate MD programs is the availability of appropriately supervised clinical practice experiences. Every medical school in Canada struggles with finding educationally rigourous clinical experiences for their students. The widespread development of regional programs and distributed educational models is largely a result of this challenge.
The logical possibility exists, therefore, to confine undergraduate medical education to foundational science, clinical science and clinical skills, leaving clinical practice to postgraduate training. It would therefore be possible to open undergraduate training to a much larger number of applicants. The “bottle-neck” in the system would therefore occur at the entry to postgraduate training, which would still be limited by clinical placement opportunities and tied to whatever information was available regarding societal requirements for physicians.
The advantages of such a program would be to allow a much larger number of students to enter what would be a shorter and much less expensive educational program, probably directly from high school. That program, properly constructed, would allow students to better understand the realities of medical education and practice, and allow for more standardized assessments on which postgraduate entry could be based. This provides an opportunity to repatriate many Canadians studying Medicine abroad. For students not successful in achieving postgraduate placements, such programs could, if appropriately constructed, provide a solid basis to pursue a variety of alternative career paths. Many of the socioeconomic barriers would be lessened.
Disadvantages are numerous, including loss of the supportive, patient and learner-centred atmosphere most medical schools currently achieve, and further dividing an already “siloed” medical education system. Such programs would, in essence, become more specifically designed pre-medical programs without assurance of admission to postgraduate training, and would require many graduates to seek alternative career paths. The very designation “M.D.” would fundamentally be devalued, unless an alternative application of the term were developed, possibly to be awarded at the end of clinical training.
And so, what began as a discussion of medical school admissions has evolved into a reconsideration of the entire educational paradigm, and the very meaning of the MD degree. I would personally find this approach highly unappealing as, I believe, would most Undergraduate Deans across the country. So why raise it? Because the system is fundamentally flawed, the meaning of the MD degree has already changed substantially, and radical proposals have a way of focusing discussion, often toward useful ends.
I welcome your views.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Making D.I.L. an important part of teaching
In our model of Small Group Learning (SGL), we ask students to prepare for the SGL class by independent study of a text, online module or lecture, directed by the faculty. This “Directed Independent Learning” (DIL) is often used, but how well is it used?
If we view the DIL as a way to have a “second” teaching session with the students, this allows us to give support, explanations and/or a rationale for the reading or viewing they are doing.
A recent study advocated 10 minute “supportive” podcasts as a way to help students understand the purpose and the key concepts and terminology in a reading prior to a group learning task. The instructors chose podcasts as a way to connect with students and allow them to listen anytime and anywhere.
Whether you use a podcast, or simply write in the Teacher’s Message in MEdTech, here are some possible aspects of “teaching” with readings you can incorporate in your “DIL” teaching.
- An introduction that explains why the reading had been chosen and how it links with course content or upcoming tasks;
- Guidance on the key elements in the assigned reading on which students should focus;
- Elaboration of particularly difficult content, including different ways of phrasing or explaining essential theoretical concepts;
- Background on any concepts new to students and not explained in the reading with the goal of creating a context for the reading;
- Grounding questions described as “designed to help students relate the material to their personal/professional reality.” (p. 82) In other words, questions that encouraged students to think about how the material applied to their interests and circumstances.
What are your thoughts on using this as a method to connect with students outside the classroom?
Taylor, L., McGrath-Champ, S., and Clarkeburn, H. (2012). Support student self-study: The educational design of podcasts in a collaborative learning context. Active Learning in Higher Education, 13 (1), 77-90.