Choosing a topic for my research project in this selective was difficult for a number of reasons. Firstly, the landscape of literature in medical education is simultaneously vast and vague. As I mentioned previously, there is no clear model for what a ‘good medical education’ comprises. One of the articles in our reading, ‘’Continuity’ as an Organizing Principle for Clinical Education Reform’ champions a longitudinal model of clerkship to emphasize a continuous learning environment, arguing that it encourages a sense of deep commitment to patients, is better suited to teaching the central themes such as professionalism, and can facilitate ambulatory care clinics as a source of high-quality interdisciplinary training.

At the same time, internal medicine residencies seem to be struggling with longitudinal clinical experiences. Some of the Canadian residency programs have previously implemented a cross-rotation ambulatory clinic into the second or third year of residency, only to eliminate them in recent curriculum redesign due to the Royal College’s exam schedule moving into the third year. Understandably, something needs to be readjusted for these changes, but I find it interesting that the longitudinal ambulatory clinic was eliminated given that recent research seems to support these experiences as some of the most valuable; at least, the most congruent with cutting-edge learning theory.

My experiences in ambulatory clinic have been varied, and overall they confirm that the value of clinic is realized in a longterm format. The current organization of this selective involves us making ‘guest appearances’ in clinics for a few hours, usually only once or twice in each clinic overall. There are some advantages to that method; our exposure is better, we see a variety of clinical microsystems, work with many different preceptors, and explore numerous high-yield clinical topics such as hypertension and COPD. The downsides, however, is that we cannot connect deeply with our patients or feel as though we are making a significant impact on their care, since we know their cases so much less than the other health care professionals involved. Similarly it is hard to establish a rhythm of learner autonomy with our preceptors; while all the staff physicians I’ve worked with have been exceptional teachers, three hours is not enough to reach the comfort level of working together and also truly benefit from the learning.

As I enter the last week of this selective, I can see that ambulatory medicine has so many benefits that ward medicine does not offer. Seeing patients in a mostly-healthy state is foreign to me; I am so used to seeing diseases at their most decompensated state. It has also exposed me to new sides of subspecialties that I am not familiar with, which is both clinically relevant and helpful for my future career selection. At the same time, from a research perspective, I did not feel familiar enough with this area of education to frame a rigorous question.

So what did I end up choosing? More about that in a future blog post. I ended up going in a direction that fit with another ‘personal project’ of mine, and will be presenting what I have so far on Tuesday. I look forward to consolidating my work so far over the next few days!

- Shara

In our noon rounds session today, Dr. Cavalcanti made a simple, passing comment that stayed with me. In the middle of his presentation, he paused to open the discussion and said, "Well, you learn more when you talk than when I talk."

This statement resonated with me because of my recent reflection on the medical education process at the University of Toronto. In our first two years, our training was predominantly didactic. Lecturers would give us hours and hours of high-quality but non-interactive teaching; for me, as a Mississauga student, it took place through a videoconference system. To ask a question, we would have to press a button and have our face broadcast on a huge screen to the 200 other medical students at the downtown campus. Needless to say, we did not press the button often.

Some measures were taken to help learn by 'us talking', such as problem-based learning sessions. However, these were a small percentage of the week, and often a few students would dominate the discussion. Instead, we would find our own ways to bring our own voices into the learning, whether that meant reading our notes aloud to ourselves in our bedrooms, debating with our peers about the best way to approach a disease, or simply trying to tutor a friend. I can say with confidence that those experiences were far more beneficial to my learning than hearing a video on my computer.

In clerkship, the teaching modalities changed. Now, we were asked to bring the answer to a question the next day, and teach the group. We stood in front of whiteboards and drew diagrams, teaching our preceptors in order to demonstrate our knowledge. We spoke aloud every case presentation, integrating our clinical and didactic learning into unified approaches. The richness of learning in our clinical clerkship was unparalleled by any stage of education I've experienced before in high school, undergrad, or early medical school. We were exposed to more new environments, team dynamics, problems, procedures and situations than ever before, while expected to work long hours, maintain consistent professional standards, and never get in anyone's way. It was certainly not was, but I learned a LOT more by participating.

Having reflected on my own education and on Dr. Cavalcanti's EBM talk, I became curious about the implications of physician's familiarity with new medical research. In a recent ProPublica article that has been circulating around social media today, Dr. David Epstein explores why doctors do not always follow best practices in the article 'When Evidence Says No, but Doctors Say Yes'. It is a fascinating article that discusses cognitive biases, the notion of 'bio-plausible' but unproven medications and why it is so hard for physicians to stop using them, and finally, the idea that physicians cannot often even conceptualize the effects of medications because of the way they are presented in research. Statistics such as the number needed to treat (NNT) are not easily visualized in terms of an individual patient, which contradicts the patient-centred care principles that are emphasized in current education. When doctors are not able to say, in their own words, what the implications are of using one intervention versus another or none at all, the best medical evidence is meaningless.

- Shara

In defense of the patient interview

I read an interesting article recently published in the New York Times entitled “The Conversation Placebo” in which Dr. Danielle Ofri, associate professor of medicine at NYU argues for the use of the patient interview as a treatment for certain conditions such as chronic back pain. In particular, she highlighted a Canadian study in which patients with chronic back pain were assigned to receive either electrical stimulation therapy or a sham treatment. Each treatment arm was further divided into two groups: one who received only limited conversation from the physical therapist and the other in which therapists asked open-ended questions and listened attentively to the answers. The results were fairly astounding. It was found that the shame treatment but high communication group reported more pain relief than the electrical stimulation but low communication group. In essence, communication alone was more effective than treatment alone.

While these results surprised me at first, on further reflection, I have personally witnessed how therapeutic a conversation with a physician can be. In these past couple of days alone, as I have been spending more time in the ambulatory setting, I have witnessed many such interactions play out with great effect. One clinic that stands out in particular was with Dr. HPK. As he is wrapping up his practice, many of his appointments appeared on the surface to be more of a “social visit”. However, on closer inspection, Dr. HPK is a prime example of how conversation can be used to strengthen the patient-physician relationship and even provide some therapeutic relief. Patient after patient left the clinic with a smile on their face, genuinely feeling better simply by talking with Dr. HPK. No change in medications, no additional investigations, just 30 minutes talking with a trusted physician and a good friend.

As I reflect back on my own experience with patient interviews, I have come to realize how privileged yet powerful of a role we play as medical students. As students, we often have the most time to spend with the patient and though our clinical acumen may not be as strong as those of our residents and attendings, we are trained to talk, and to listen. In light of this unique position, perhaps there is a role for training medical students to maximize the potential of the patient interview. For instance, one topic that I felt was lacking in our curriculum was counselling. While we were always guaranteed a “counselling” station on our yearly OSCE’s, I felt like I was never explicitly taught about how to conduct a therapeutic counselling session. Several tips and tricks were shared about breaking bad news, however, not much attention was given to other aspects of patient interviewing such as motivational interviewing. On a more personal level, I will learn to cherish these precious moments that we have with patients, not yet burdened by the competing demands that come with residency. I will take my time, be present, listen empathically and respond appropriately. If there is even a small chance that my conversation with a patient will have a therapeutic benefit, then that’s reason enough to try.

~CW

Tonight, I am reflecting on the experience of learning from Dr. Ho Ping Kong. I had this opportunity twice in my first week of this selective, and will spend time with him again tomorrow afternoon. All first year medical students at the University of Toronto received a speech and a free copy of Dr. Ho Ping Kong's book at the beginning of our medical careers. It is fitting to revisit his principles in my last few months before graduation.

On our first day of this selective, we had a few free hours in the afternoon and were sitting at our desks, beginning to delve into the research papers from the rotation. Seeing us sitting idle, Dr. Ho Ping Kong ushered us into his office, which was stacked with cardboard boxes, bookshelves of autographed medical textbooks, and neatly printed out emails in stacks on his desk.

The following hours were the most unusual lesson I've received. Dr. Ho Ping Kong pulled out a box of photographs, filed like cue cards. The first: an anxious woman in April 2003 - what is the diagnosis? We studied her face for rashes and skin for discolouration, until we landed on the white mask around her neck. SARS. The second: a pair of brown hands, perhaps with a tinge of orange. Addison's.

It was not simply the photos that made the lesson interesting, though. Interspersed with telling us the story, HPK would pause to ask where we were born, our ethnic background, our home campus at UofT. I was so impressed when I told him I was Guyanese, and he remarked 'famous for Burnham and Jagan', referring to the political conflict that led to my parents leaving their home country before I was born. And then, smoothly, he would return to teaching us medicine again.

When I was in clinic with HPK later that week, I saw how his unique knowledge of culture, language, politics, geography and trivia were so integral to his teachings. A woman came in with a history of oral ulcers, and when we arrived in the room, he began asking me about the Chinese silk trading routes. Little did I know that she had Behcet's disease, most prevalent along these historic paths.

The doctor-patient relationship that HPK has with his patients is at times quirky and yet full of compassion. When a woman came in with cancer, fearful about an error in her management, he spent the first ten minutes of her appointment asking her about the current election, the derivation of her name, and her grandmother. Yet at times she was so anxious that she was in tears, and he would reassure her with composure and kindness. At the very end of the appointment, he revealed that he had emailed a close friend at TGH who would provide her with a second surgeon consultation and ensure she was well cared for. His incredible patient advocacy was quiet and subdued in that way.

I look forward to spending more time with HPK in the coming days, and to reflect on what I have learned through the process.

- Shara

It has taken some time for me to write my first blog post. Instead, I have spent the past two weeks carefully moving through the reflections of students before me, imagining their experiences and trying to decide what my main goals for this rotation would be. Previous students have discussed the near-mystical experience  My main takeaway has been that there is a world of possibility. As a selective experience, this rotation is intended to better prepare me for residency. I have reframed it in my own objectives, instead hoping that it will inspire in me a passion or interest for some part of medical education research that I can bring into residency with me, and therefore be a step towards one of the pillars (hopefully!) of my future career.

At the near-halfway mark of this rotation already (how quickly time passes in the post-CaRMS world!), I already have a much better understanding of the landscape of medical education research. Why has struck me is the different philosophical schools of thought on medical education. Scholars of the past cannot agree on the best model to characterize med ed in the first place, much less the most robust methodology to study it. Equally, there is still an open question in the existing literature (that I have read so far) about who should be doing medical education research in the first place.

Perhaps my favourite article so far has been Norman's 'Fifty years of medical education research: waves of migration' where Geoff Norman discusses the three generations of med ed researchers, comparing them to immigrants in a new country. The first generation 'emigrated' from other fields of training, whether statistics, psychology or qualitative research, to break new ground in medical education topics. They used 'common sense' to make their way through the field. The second generation were actively recruited from the fields that the existing med ed terrain lacked, such as cognitive psychology and psychometrics. They straddled both the 'old' and 'new' worlds.

And the third generation, the one that I hope to belong to, are usually in the healthcare field and have 'actively chosen this career path; mentored and taught by medical education researchers'. The article is a fascinating read at this stage in my life because as I prepare to delve more deeply into this research field during my selective, I find great value in orienting myself to its historical roots, and my own potential role in its future.

From what I have seen so far, this selective is full of unique cross-disciplinary learning activities. Whether I am participating in morning report, in a post-discharge ambulatory medicine clinic, or trying to solve one of HPK's photographic riddle cases, I am already learning so much about the flexibility of teaching and learning internal medicine. Tomorrow, I aim to choose an area to focus my own research project for this rotation. I am excited to get started!

- Shara

In defense of selectives

"What selective are you on?"

I dreaded answering this question because for a good week after starting this selective, I still struggled to describe what I was doing to others. Not only did I find it difficult to describe what I was doing, but also WHY I was doing it. I knew that I was interested in internal medicine and in medical education, but I suppose that I was less clear on what my learning objectives were for this selective.

So then I took a moment to think about the purpose of selectives. According to our course description for Transition to Residency, selectives "will allow students to work more independently than they did during their 3rd year core rotations, but with supervision commensurate with their pre-MD status. Students will be engaged in the workplace environment of the selective and are expected to gain tangible knowledge, skills and attitudes from it; they will also have responsibilities to study, independently, the population and systems they encounter in the selectives."

For me, selectives are a time for career exploration. I believe it should be a time for students to expand their ideas of what it means to be a physician and test out some areas in which they can be a "clinician +". I've heard terms like "clinician-scientist" or "clinician-educator" thrown around quite a lot and I always figured that selectives were a good opportunity to explore what these terms actually meant. It was a time to meet scientists and educators and talk to them about how they integrated their side-passions into the practice of medicine. It should also be a time to start carving out our own paths in our fields of interest. With residency literally around the corner, there is no better time than now to lay the foundation for a rich and fulfilling career path.

In the end, I see selectives as a chance for soul-searching and exploration, 2 activities that (unfortunately) do not get much attention in our busy medical school curriculum. Our portfolio sessions do cover some of it but mostly through stories and words. Selectives are an opportunity for us to put these words into action.

While I feel that this CEEP selective will allow me to do just that, I wonder whether other selectives are equally as set up to help their students through this process. I know of many other selectives that honestly don't seem to different from an elective in that they are very focused on developing clinical acumen. From a curriculum design perspective, I strongly feel that selectives should be a time to develop interests outside of the typical clinical encounter. Perhaps the objectives of this period need to be more explicitly stated? Perhaps we should be presenting students with a more tailored set of experiences that will encourage development of side-passions? Either way, I am thankful for the opportunity to explore questions like these while spending time with top-notch clinicians and educators. Let the soul-searching begin.

~CW