Today, I am reflecting upon an integral resource for medical students: residents. Over the course of my medical education thus far, I have had the opportunity of learning in a number of different environments. From academic centers to community hospitals to private practices, each experience has offered its own unique approaches to teaching.

As a student at the Mississauga Academy of Medicine, most of my core clerkship rotations took place in community settings. During these rotations, the reality was that there was no abundance of students around. For the majority of my experiences in Mississauga, I was working directly with a staff physician, and no other learners. For instance, in core rotations such as emergency medicine, anesthesia, and even most surgical rotations, there were no residents around. However, I did end up doing a single, 6-week rotation in obstetrics and gynecology at Mt. Sinai hospital. This is really when I first experienced a world with residents. In this setting, there was often actually more residents around than there were other medical students.

A world full of residents has its own pros and cons. Firstly, there is no doubt that, as a medical student, residents are an extremely valuable resource for learning. In contrast to most staff physicians, residents are closer to the medical student experience, and remember what it is like to be a medical student. In general, they are better able to relate to our level of knowledge and experience, and this usually translates into an excellent teaching environment. However, on the other hand, having many residents around can also mean that certain experiences are taken away from you. In particular, I generally found that many “hands-on” tasks that I had practiced in Mississauga, such as intubations in anesthesia, or assisting the surgeon in the OR, were instead assigned to the residents.

With all this in mind, I hope to think back to this reflection next year, when I myself am a resident, and have the pleasure of teaching medical students. I foresee challenges when it comes to the delegation of certain tasks, because, as much as I would love to let medical students practice, as a resident I will have to ensure that I am competent in all areas. I’m sure that this is a conflict that all residents before me have had at one point or another, and having reflected upon these thoughts now, I feel confident in my ability to handle it moving forward.

- AS

Part 6 – Competence By Design

Today, Dr. Jolanta Karpinski from the Royal College of Examiners presented on the topic of Competency Based Medical Education during a special CEEP rounds. Essentially, the entire Canadian medical and surgical residency program is undergoing a massive overhaul with a singular mandate to update the current way we train residents into competent physicians.  She argued that though the current system trains excellent doctors, the reality is that it is outdated and the evidence suggests that our methods could be much improved upon. The current model assumes that the more time a learner spends on an activity; the more the learner absorbs and excels. This method, however, has had difficulty keeping up with the increasing scope, demands, and complexities of medical care. As such, more and more newly graduated specialists have identified increasing knowledge gaps and a feeling of unpreparedness for independent practice. The system has also identified that educators are struggling to define clear learning objectives and adequate assessment tools; and as such is finding it difficult to determine when a learner is falling behind. In other words, how does one define the quality of their assessment program?

The solution, one hopes, comes with Competency By Design, which is not CBME in its purest form as it is unlikely to change the length of training program, but instead, it re-conceptualizes time as a resource for acquiring competencies. It is outcome based and is designed around the question: “What abilities do physicians need at each stage of their career?” It organizes physician training around desired hard outcomes that must be accomplished - known as EPA’s – entrustable professional activities.  EPA’s are tasks that integrate a number of milestones and abilities that are given by supervisors in a clinical setting to determine competence. EPA’s are designed around the CanMED roles. And ultimately, the Royal College will grant board certification via the successful completion of the licensing examination AND required EPA’s.

I think overall, this is the right move towards modernizing our medical education and in producing higher quality physicians. My dispute though, is that if that we’re trying to move towards competency based education, then why shouldn’t there be an option for a shorter training program if the resident is indeed competent for independent practice. For example, in this year’s entering ophthalmology residency class, there is a foreign trained ophthalmologist who also completed an additional 2-year vitreoretinal fellowship at the University of Toronto – however in order to remain and practice in Canada, the system mandates he retrain in a Canadian ophthalmology residency program. Is he competent as a PGY 1,2,3,4? I would think so, and it would be very easy to assess whether he can perform all the EPA’s capably. Should he not be allowed to fast track a true Competency By Design residency-training program? I would hope so…

 My realistic/pessimistic thoughts are that for every residency program, there is still very much a “service component” that needs to be fulfilled, and having “independent practice ready” residents graduate sooner will leave a huge void in this service. Residents who are ‘left behind’ will have an unrealistic demand in work in addition to the logistical nightmare this will create. However, my hope is as implement CBD in our residency training, we will eventually evolve to true CBME. 

I look forward to seeing the manifestations of the incoming CBD model of training, especially as I, myself, transition from medical student to resident. – AC

            Throughout the CEEP selective, there have been numerous opportunities for learning through practice. Whether it was at morning report, noon rounds, or clerk teaching, the option of volunteering for case-based practical scenario learning continued to be presented to us. And more often than not, I’m proud to say that I am comfortable in participating in this type of learning.

            However, it wasn’t always like this. At the beginning of medical school, I usually would try to stay away from engaging in this type of learning. I found that I often felt pressured to perform, and worried that I might mess up in front of my peers. I think this was a feeling that many medical students have. As the time has passed, though, we’ve all been exposed to this type of teaching style over and over again. And this is how I came to realize a couple of things. First of all, this method of teaching is very effective, especially when the student is well accustomed to it. As practical exams are often framed in similar styles, it is particularly effective for exam preparation. Additionally, I realized that most students feel the same way about this style of learning, and are generally quite supportive of their peers.

            Transitioning into residency, I hope to take more opportunity of these types of learning experiences. Furthermore, as a resident, I look forward to being able to present this type of education to medical students. By doing so, I hope to allow them to practice with this practical style of learning in a safe environment, so that they may become comfortable with it early on in their medical education, and subsequently make the most of their own educational opportunities.

-AS

Part 5 – Our Teaching Session

As a part of the educational requirement of our CEEP selective, AS and I were tasked with leading a 1-hr teaching session on a topic of our choosing. Coming up with what to teach was actually the most difficult part of this assignment. Having been on the receiving end of countless lectures, we empathized with how difficult it would be capture the attention of our audience for the full 60 minutes. We were also well aware that our colleagues were a few short weeks from graduating medical school – and this certainly didn’t help our cause. Curriculum design, in many ways, can be just as difficult. We wanted teach something that was interesting, but not esoteric. It had to be relevant and useful for the general physician, or any doctor, regardless of specialty. We also wanted to make sure that our session was engaging, interactive, and safe. Safe, as in a ‘safe place’ to ask even the “dumb” questions and a safe place to offer genuine, constructive feedback.

The title of our lecture was “3 Neuro Eye Conditions that Should Not Missed in Medicine.” This was a familiar topic for AS and I as he intends on pursuing emergency medicine, and I will be starting a residency in ophthalmology. In our audience, however, there was a future psychiatrist, radiation oncologist, pediatrician and internist  - buy we maintained that regardless of specialty, these three conditions could potentially walk into their clinic and should raise red flags and warrant urgent investigations. Our session covered how to properly assess pupils and how to interpret abnormal findings. We distributed penlights as souvenirs and had people pair up to practice the physical exam. We also utilized a very useful interactive program that simulated different pupillary abnormalities from normal responses, to RAPD, to Horner’s syndrome. We went through 3 cases: Third Nerve Palsy, Temporal Arteritis, and Horner’s syndrome and ended the session with useful resources for the trainee in learning about neuro-ophthalmology. In the end, the session was extremely well received. Our audience was engaged throughout, took notes, requested the slide-deck, and asked very thought provoking questions. They told us that they could certainly apply what they learned today in their own work settings – which ultimately, is what we were hoping for. - AC

            At the end of last week, I had the opportunity to attend a half-day at Bitove Academy. Leading up to this experience, I had minimal knowledge about the program, and how it functioned. I was made aware that the academy was a place where elderly persons with mild to moderate cognitive impairment came to engage in a day program and participate in various mentally and physically stimulating activities. This program differed from other, somewhat similar programs, in its approach to care. In brief, the philosophy of Bitove Academy is non-medical, and it veers away from treating its participants as patients. As such, the staff members at Bitove Academy are not provided with charts, and therapy is not necessarily the end goal of the activities that participants engage in.

            My experience at Bitcove Academy was overwhelmingly positive. The academy had developed a strong sense of community, which I believe is a very important factor for seniors’ wellness, in general. Additionally, the wide array of activities planned for the day ranged from crossword puzzles to salsa dancing lessons to watercolour painting. This ensured that each individual’s interests were catered to. While I only spent a few hours interacting with the participants and engaging in their activities, it was clear to me that each participant was thoroughly enjoying themselves.

            Moving forward in my medical career, the experience at Bitove Academy will stick with me. I have realized that it is important to keep an open mind about different types of care models, and different approaches to care. Often, these alternative models can be equally as effective as traditional approaches.

-AS

Part 4. Bitove Academy

Yesterday, I went to the Bitove Academy to experience “patient centric” care in its truest form. The entire experience was very unique for me as a medical student since 1) I’ve never worked with people afflicted with dementia and 2) had never been exposed to such a unique model of care. Over the 4 years of med school, I’ve been accustomed to the standard physician-patient paradigm where issues and problems are addressed with solutions and treatment plans. Standard medical therapy is very ‘prescriptive’, or ‘regimented’, or  ‘a means to an end’, if I may. Whereas at Bitove, the ‘therapy’, if I may even call it that, is intrinsic to the process. There may not even be an ‘issue’ to resolve, but rather healing and growth simply comes from being present in the moment and by embracing relationships. The members of Bitove are all afflicted with memory loss to some degree, but more importantly, their care is dictated by nobody but themselves. Program assistants are there to help navigate and interact, but the members are essentially free to engage in whatever they please.

I recall one special encounter while listening to Buddy Holly with a member with advanced dementia. He was essentially non-verbal and required 1-on-1 care, but when the music came on, he would dance, spin, twirl, clap, and sing out the lyrics. It was uplifting to say the least.  I spent the rest of the day dancing to ABBA, watching improvisation performance, playing crossword puzzles and colouring with the different members there.

Overall, I think the experience is useful and healthy in broadening the perspective of future physicians. Medical students should be exposed to this model of care in their training and attempt to incorporate parts of it into their own practice, wherever possible. For example, the areas of where this may be useful are somewhat obvious for geriatricians, pediatricians, and palliative care physicians, but I argue even surgical practices may benefit with caring in this way. Encouraging freedom of expression, music and other art forms in recovery areas or waiting areas, may promote better communication and outcomes with those dealing with cognitive impairment. -AC

In the middle of this past week, I had the type of learning experience that I have a feeling I will miss during residency. You see, my peers and I have all come to realize that, as medical students, we have the unique privilege of being able to spend ample time with each of the patients we see, which is not necessarily the case as a resident or staff. As such, we have the opportunity to learn from our patients, by speaking to them about all sorts of things that may not be directly relevant to the encounter at hand.

In this specific example, I was in cardiology clinic, seeing a young man who had suffered a myocardial infarction a few years ago. He explained that he had been a heavy smoker in the past, and had actually managed to quit before he first started experiencing chest pain. As a CC4 who will be starting a residency in family medicine next year, smoking cessation is a topic that will be very relevant to me, and so I took this opportunity to ask him about his experience. What ensued was a long conversation about the factors that both helped and hindered his efforts to quit smoking, as well as advice for me to take forward into my future practice.

Unfortunately, I suspect that experiences like this will be few and far between as a resident and staff physician. With time and efficiency being such valuable factors in a family medicine practice, it will become harder to allow myself to take the extra time required for this type of patient-focused learning. Instead, I understand that my learning style will have to be modified in order to adapt to the changes that await me in residency. I guess I will just have to wait and see what works best for me in the coming years.

-AS

Part 3. Does Pimping Work?

Earlier this week, I spent a morning in clinic where instead of seeing patients and reviewing cases, I shadowed an attending physician and saw his patients together. For each visit, I was systematically bombarded with questions on whatever condition the patient had. If I was ever stumped or answered incorrectly (which was unsurprisingly often), he would jokingly quip back with something along the lines of “Oh good, you attended that lecture!” or “Aren’t you graduating medical school in a couple of months?” Essentially, I was being pimped.

I actually respond quite well to pimping. I tend to embrace the feeling of uncertainty when being ‘put on the spot’. This fuels my own competition, but admittedly, it’s not always a comfortable position to be in.  Fortunately in this instance, the staff was in no way demeaning or trying to enforce his superiority, but rather, the entire experience was jovial and low pressured. One can argue that it was also effective – he taught me some things that I’m unlikely to forget going forward. To reference my last post on qualities of an effective tutor, this staff certainly exhibited subject matter expertise but his social and cognitive congruence was arguably not to par.

Despite my experience, most medical students do not enjoy being pimped. The time-honoured tradition of aggressively testing one’s knowledge base, often in front of patients, is commonly seen as a ‘rite of passage’ for medical students as they advance in their training.

I argue, in the context of teaching, pimping — especially when done aggressively — does a poor job of evaluating clinical knowledge, overall clinical judgment, and identifying how well a student is improving.

Given the large amount of information in medicine, asking a few selected, random questions does not reflect the breadth of what a student knows and understands. The realistic consequence of pimping is that medical students tend to answer only those questions they are completely sure about and avoid speaking up when they are less sure. This reinforces the idea that mistakes are bad, rather than affording them an opportunity to learn from them.

I believe there is much value in answering a question incorrectly. An effective tutor identifies the error and teaches around it such that the student becomes a better doctor for it. The opportunity to ask questions without being ridiculed is also essential for learning. Ultimately, the culture in medicine needs to move away from pimping, and towards an environment where medical students feel safe to make mistakes. - AC

Part 2: What Makes an Effective Tutor?

Yesterday, Dr. Silver facilitated a morning round discussion in which we went over thyroidoxicosis in an elderly patient with atypical presentations. I found his session highly engaging, entertaining, and educational. In Schmidt and Moust’s essay on What makes a Tutor Effective? they conclude that effective tutoring is a product of three distinct, yet symbiotic qualities: the possession of suitable knowledge base under the topic of study (expertise), a willingness to engage students in an authentic way (social congruence), and a skill to communicate and express oneself in a language that is understandable by students (cognitive congruence). Dr. Silver exhibited all three of these qualities with near symphonic execution. Without a doubt, he possessed the expert knowledge required to facililate a discussion that included the attendance of both medical students and recent Royal College fellows. Indeed, AS and I reflected after the session, that the reason why he was so effective in leading was because he knew absolutely everything there was to know about hyperthyroidism and was often way ahead of his learners – predicting questions well before being asked. As such, he was able to nagivate the discussion in a way that was appealing and kept the learners engaged. He was also sensitive to the different levels of learners in his audience. For medical students, he would serve up slow pitch meatballs in order to build confidence and for the more senior resident, he would adjust his questions accordingly – always with a disarming and welcoming approach. 

Dr. Silver, I maintain, is an ideal example of an effective tutor – one that I hope to emulate in my future career. - AC

Today, I finally met Dr. Ho Ping Kong. Yet, after reading the previous posts on this blog, as well as hearing stories from my fellow peers, the experience somehow still wasn’t what I was expecting – it was better. As Dr. HPK’s years of practice will be officially coming to an end, his clinic had a completely different feel from the type of clinic I am used to, and it was a very refreshing experience. He had the time to chat with his patients about things other than their diagnoses and management plans, and you could tell that each patient really valued their relationship with Dr. HPK.

And then there was the teaching. Once again, this was a very different experience from what I was accustomed to. Rather than covering key teaching points between patients, Dr. HPK would probe us with thought-provoking questions, both during and after each patient encounter. If we had difficulty with a question he asked, he also enjoyed giving hints that often went right over my head. This made the learning fun. Additionally, I have always found that associating disease entities with specific clinical encounters made the learning stick better. By combining these methods, Dr. HPK created a very positive and effective learning environment.

Moving forward in our medical careers, my classmates and I will all have the unique opportunity to go from medical students who strictly learn, to medical residents who learn, but also teach. In doing so, we must all develop our own teaching methods, and a lot of this will come from what we have found effective in our own learning. Next year, when given the opportunity to teach medical students, I hope to incorporate some of Dr. HPK’s tactics, in an effort to keep learning both light and fun, while still ensuring I am imparting knowledge.

-AS