Selection Reflection

Hard to believe that we are at the end of the CEEP selective already. Like my colleague mentioned below, as part of our selective, we were to chose a topic in medical education and present it to our colleagues. We decided on simulations and their roles in medicine. Although there are a variety of simulators that already exist, research in this field is still in its infancy, with very few randomized trials demonstrating efficacy. I think the safest conclusion to make at this point in time is that when appropriately used for specific skill sets, simulation can be a valuable adjunct or aid to traditional clinical training. Ultimately, it comes down to individual motivation and hard work that allows one to excel in a field, but it is interesting to see how technology has brought innovation to the field of medication education, which has remained fairly unchanged for the past century. We are very glad that our presentation was well-received and stimulated quite a bit of discussion among the audience. We are also grateful that Dr. Panisko and all of our colleagues were present and actively contributed throughout the talk. It was a fantastic learning experience for Laura and I, and we hope our colleagues benefited from it as well.


This CEEP selective has certainly been a very fruitful experience. Many of the cases we saw in the past 3 weeks were disorders I had only ever encountered in lectures. This is certainly the place where the most interesting and unique cases in internal medicine gather. Furthermore, the staff internists that we had a chance to work with were all incredible educators and clearly had a genuine passion for teaching. I would highly recommend this selective not only to folks who are interested in internal medicine, but to anyone who loves to see cool cases on a daily basis and work alongside excellent clinical educators.

Now on to the CaRMS interview tour. Best of luck everyone!

-Roy

Lessons from the masters

“There is no more difficult art to acquire than the art of observation”, said Sir William Osler many years ago. And despite the leaps in medical science and technology, it is as true today as it was then. Dr. HPK illustrated this beautifully this week when he related to us several stories about former patients whose diagnoses were clinched based purely on the observation of the patients’ appearance, signs, and symptoms. Diagnoses ranged from aseptic endocarditis to thyroid storm and polyarteritis nodosa. Dr. HPK explained that the basis of his diagnostic acumen is careful observation and use of all senses – sight, smell, touch, and listening – which can often provide information critical for making a diagnosis. It seems that with the advent of blood tests and imaging studies at the snap of a finger, there is a declining use of inspection as part of the physical exam. As Dr. HPK’s cases demonstrated, weeks of diagnostic tests that failed to yield a diagnosis, could have been avoided had the art of observation played a more prominent role in the process.

As I wrap up this rotation, I think one of the most important things I will take with me is that although the way medicine is taught may have changed and evolved over the years, the art of observation remains vital.

And because I can’t resist quoting the master again:

“The whole art of medicine is in observation… but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that you can do.” – Sir William Osler

As this will be my last post, I want to thank Dr. HPK and Dr. RC for the great experiences I have had in this Selective!

-Laura

The future is here: Simulation in Medical Education

One of the objectives of the CEEP selective was for Roy and I to come of with a topic in the realm of medical education and prepare a presentation on it. Early on, we both agreed that we would like to learn more about the role of simulation in medical education – when and how it came to be, and what the future of simulation is. The reason for this is that we have both had simulated experiences throughout clerkship and we were intrigued to learn if there is evidence that supports the integration of simulation into the medical curriculum. A few days ago, we had the opportunity to present our findings to our CC4 colleagues. We discussed the history of medical education, types of medical simulators available, advantages and disadvantages of using simulation in medical education, research evidence supporting its use, and what the future holds. The traditional premise of medical education in North America has been “See one, do one, teach one”. In summary, we agreed that simulation is a powerful tool to bridge the gap between “see one” and “do one” but in order for simulation to realize its potential, it needs to be more thoughtfully integrated into the curriculum and faculty need to be trained and readily available to provide instruction. Furthermore, more rigorous research is needed to demonstrate the effectiveness of simulation in medical education.

-Laura

Medical Education

As we read more about the existing literature in medical education, it's quickly becoming apparent that a wealth of knowledge already exists in the field. It's no surprise that as research in this area is evolving, some discussion is focused on how the research should actually be carried out, rather than the actual educational topics themselves. It becomes more of a philosophical discussion rather than a scientific one, the kind we are less comfortable in. On the one hand, Geoff Norman advocates for a reductionist approach to research in medical education, the kind very similar to the evidence-based medicine we've been exposed to all throughout medical school. He believes in controlled studies where only one variable is altered at a time to assess for its effect, much like how an RCT comparing two drugs would take place. In contrary, Glenn Regehr, who was apparently Geoff Norman's student at one time, believes that medical education research is far more complex, with many more variables and factors that need to be taken into consideration. A simple randomized trial is likely insufficient. It's quite intriguing reading the rebuttals between these two, as they certainly provide more perspective on the directions that research in medical education are potentially headed. Having gone through many years of scientific education, I lean more on the side of Geoff Norman, and believe that controlled trials would provide the most objective information. However, I certainly think Glenn Rgehr's points are crucial as well, as any time human behaviors come into play, things are no longer so black and white. Sociological, psychological and other factors could confound results even in the best-designed RCT. At the end of the day, only time will tell the direction that medical education research is going. As a learner, I feel very fortunate that so many individuals are constantly looking for better ways to disseminate the ever-growing body of knowledge in medicine.

I thought I'd end the entry with a joke of the day:
What are the strongest days of the week? Saturday and Sunday, because the other days of the week are weeak-days.

-Roy

The meaning of advocacy

To echo my colleague’s thoughts, I have greatly enjoyed my time in Dr. HPK’s clinic. It has been a fascinating week of seeing patients with rare diseases and the knowledge I have gained is sure to serve me well in my future career as a family doctor. During clerkship, I gained an appreciation for the ‘bread and butter’ of medicine but hardly encountered the rare cases, so this selective experience has been insightful.

In addition to expanding my knowledge base, there is another aspect of medicine I want to discuss – the role of the doctor as a patient advocate. What does that mean? Advocacy is of paramount importance to the doctor-patient relationship and to be an advocate is to advance the health care interests of patients. The health care system is complicated as it is and having a doctor who actively and responsibly advocates for patients’ interests is fundamental. In Wednesday’s clinic, I saw firsthand how powerful advocacy can be to effect progress and change. One of Dr. HPK’s patients had recently been diagnosed with a tumour that was amenable to surgical resection. However, the patient’s surgery had been rescheduled three times so far, much to the frustration of Dr. HPK and the patient himself. Rather than accept this as a systemic problem out of his hands, Dr. HPK began firing off e-mails to surgical colleagues and making telephone calls. This process took no less than one hour and Dr. HPK’s perseverance to try and help his patient have his surgery as soon as possible was very admirable. There are many things a doctor does ‘behind the scenes’, of which advocating for patients is one of them. I want to be this kind of doctor too – someone who helps patients fight their battles, who takes time to write that extra letter or make that phone call, if it means that patients will ultimately get the best of care.

-Laura

Ambulatory Clinics

My colleague and I have completed several clinics with Dr. HPK now. The spectrum of disorders seen is simply mind-blowing. At least 80% of cases we encountered thus far I have never came across in a clinical setting. We saw a patient with Kennedy's disease, also known as spinobulbar muscular atrophy, a X-linked recessive lower motor neuron disease with a significantly better prognosis than other motor neuron conditions such as amyotrophic lateral sclerosis (ALS). For the first time in my medical training, I saw true fasciculations of the tongue - something I'll never forget. We also came across system sarcoidosis, Grave's disease, dermatomyositis (with classic appearances of Gottron's papules, periungual erythema, and a heliotrope rash), and possible systemic mastocytosis. If anyone ever asks me to recommend an elective/selective where they get to see the most rare and interesting diagnoses, I'd make sure to let them know about Dr. HPK's clinic. What's even more impressive is Dr. HPK's ability to make many diagnoses based simply on observation and physical exams. These clinics have truly been invigorating and I'm looking forward to seeing more interesting cases throughout the rest of the selective.

-Roy

Today's Lesson

To change it up from my previous post, which was about my initial impressions of medical education research, this post will be about a clinical experience I had today. I saw several interesting cases, including dermatomyositis. Although I had read and seen photographs of clinical signs of dermatomyositis, it was a great learning experience to see the findings in an actual patient. The characteristic heliotrope rash was very obvious, as were the Gottron’s papules, and both her cheeks were erythematous. However, the patient insisted that it had taken a long time for her to be diagnosed, despite repeated visits to her family doctor. We also had an insightful discussion on the pros and cons of awaiting an official diagnosis before initiating therapy. In the end, it was decided that she should have a muscle punch biopsy to seal the diagnosis prior to initiating treatment. As the patient was getting ready to leave, we returned to her room to give her a bloodwork requisition and I was surprised to see that her face was completely clear and rash-free. How had her rash miraculously disappeared? She replied that she had just applied camouflage make-up to conceal the redness. Even upon closer inspection, I could not see any traces of make-up, which leads me to believe that make-up really can do wonders. It also turns out the patient had been wearing make-up at each of her family doctor visits, thus camouflaging her rash. The moral of the story? Don’t conceal a rash with make-up before visiting a doctor.

-Laura

Initial Impressions

It's been almost a year since I completed my core internal medicine rotation, but the GIM orientation on the first day of the selective brought me right back, as if it was just yesterday when I was on team medicine. Things are a little different this time around, as I'm spending the majority of my time in clinics as opposed to on the wards. This is a great chance for me to experience another aspect of internal medicine, since our core rotation consists of 8 weeks of CTU with only a few half-days of sub-specialty clinics. We have already seen some incredibly interesting cases thus far, including dermatomyositis, Addison's disease, and Grave's disease. The wide spectrum of cases seen in these clinics provides fantastic learning opportunities, especially when we have time to discuss each case as a group. Furthermore, the medical education component of this CEEP selective is eye-opening. As much as we have been completely immersed, quite literally, in medical education for the past 3.5 years, the topic itself has almost never been directly discussed or formally taught to us. It truly amazes me how much research exists in the realm of medical education, and the rate at which it's growing, as researchers continue to find optimal ways to disseminate the ever-growing body of knowledge that exists in medicine.

This week has been a fantastic start to the selective and I'm excited about the next two weeks.

-Roy

Reflection on medical education

My selective in Ambulatory Medicine at TWH is off to a great start. I signed up for this rotation because its aim is to combine the topic of medical education with clinic experiences. Medical education is a field coming of age but unfortunately its themes have not been emphasized in our curriculum. As such, I hope to broaden my understanding of medical education topics in the coming weeks.

A good place to start was reading the articles assigned to us, which range from topics about the shortcomings of the traditional clerkship curriculum (lack of continuity among different learning experiences being the main issue), an overview of medical education in the past 50 years from the perspective of a veteran in the field, Dr. Ronald Harden (who helped pioneer the OSCE and Harvey simulation teaching!), the qualities that make a tutor effective (subject matter knowledge and personal attributes like empathy, authenticity, and communication skills), and several theories of medical education research. I admit that it was difficult to understand and follow the line of argument in the latter paper, titled “Chaos, complexity and complicatedness” by Geoff Norman, though a rebuttal commentary, titled “Highway spotters and traffic controllers” by Glenn Regehr assured me I wasn’t the only one.

In any case, my readings so far have increased my understanding of the breadth of medical education research and that much remains to be done. As Dr. David Hirsch commented in his paper titled, “’Continuity’ as an organizing principle for clinical education reform”, the ultimate purpose of medical education is to meet the health needs of society. Getting there is another matter, but since the field of medical education is an emerging one, there is promise for the future.

-Laura