Dealing with changes to clerkship during a pandemic: perspectives and lessons learned at Dalhousie    

Christopher Gallivan,1 Magnus McLeod1

1Dalhousie University, Nova Scotia, Canada


Across the globe, clerkship directors and other educators had to deal with the unprecedented chaos caused by the COVID19 pandemic leading to the cessation, modification, and then resumption of clerkship.  This posed a challenge for educators – and students. There had to be a balance between maintaining a safe learning environment for students and ensuring that students had adequate clinical learning experiences but still allowing students to complete their clerkship year in a way that does not completely disrupt the learning of the following cohorts’ clerkship year.  We would like to share some perspectives and lessons learned from the point of view of the internal medicine clerkship program at Dalhousie University.

One thing that certainly took us by surprise was the speed at which things changed during the first wave of the COVID 19 pandemic.  At Dalhousie, for example, we went from a Monday morning introduction for students starting their third of four clerkship blocks with some passing discussion about the evolving pandemic to a Friday briefing that same week that clerkships were suspended indefinitely across Canada.  It was obviously an incredibly stressful time for students; made worse by the fact that for most of their questions (such as how long they will be off, how this will affect their graduation date, how this will affect residency matching), we simply did not have any answers.  During this time, we felt it important to make sure students were receiving clear and accurate messages and not getting different information from different sources. To do this, I found myself communicating much more with my fellow clerkship directors as well as our undergraduate medical education department.  This also led to, what was for me, both a humbling and frustrating experience of having to tell students with legitimate questions or concerns that we did not have answers.  This involved fighting the natural tendency as an educator to answer questions and provide reassurance. Still, in the long run, it was certainly my experience that telling students to wait for more information caused fewer problems than students getting conflicting information from multiple sources.     

As the year progressed it became clear that the turmoil of stopping clerkship would pale in comparison to the challenges of restarting it.  At Dalhousie, after much discussion, it was decided that the final two clerkship blocks of the current class cohort as well as the first block of the following year’s cohort (that which started in the fall of 2020) would all need to be shortened with each department deciding how to give students adequate training in less time.  I came to the profound but obvious realization that it would be impossible to deliver all the content we do in normal year.  I found myself essentially applying “triage” thinking to the curriculum and focusing on the things that were vital or ‘life saving.’ We ended up deciding to keep the full length of what we felt were our core internal medicine rotations of the MTU (Medical Teaching Unit) and our geriatrics rotations while shortening the time for selectives in outpatient and subspecialty medicine.  Although this certainly altered the experience of clerks, I felt we were able to provide students with the necessary learning in core internal medicine patients and illnesses.

Although there were many challenges to this year, it was also an opportunity for educators to improve and innovate.  We were pleased to see how many of our clinical preceptors and other educators were willing to step up and help find creative solutions to keep students engaged.  For example, many of or preceptors involved students in virtual care and remote or phone consults even though these were new for students and preceptors alike.  This allowed students to be part of the learning and innovation process as they worked with their preceptor to navigate the new clinical environment.  Some preceptors also found ways to involve students in patient care using new techniques, such as taking a table into a patient room and showing the physical exam and history without bringing in their whole team of learners.  The ability of our educators to be open and creative undoubtedly helped our students to get back into the clinical environment and resume learning.       

As we look ahead to the ongoing challenges, we can use some of the lessons we learned during the pandemic to prepare for the future.  By focusing on clear and open communication (even if this means telling students we do not have the answers), realizing that education will be different and that we may need to triage to protect the most important parts of our curricula, and being creative and open to new methods of teaching, we can hopefully make 2021 a smoother year.

 

Are we undervaluing the teaching of empathy to pre-clerkship students: another side-effect of the COVID-19 pandemic?

Shaishav Datta,1 Wafa Khoja,2 Meera Dalal-Burns 3

1Temerty Faculty of Medicine, University of Toronto, Ontario, Canada; 2School of Medicine, Queen’s University, Ontario, Canada; 3St. Michael’s Hospital, Ontario, Canada.


Compassion and empathy are integral qualities in a good physician. Empathy is a multidimensional construct conveyed through verbal and non-verbal expressions, such as sustained eye contact, careful listening, embodied experience, and tactile contact.1 Both the quality of clinical communication with patients and patient wellbeing are improved when patients interact with physicians whom they perceive as empathetic.1,2 Thus, a physician’s ability to build a strong, therapeutic relationship is grounded in their repertoire of non-verbal skills. But how are these skills taught? While the vast majority of our medical curriculum is knowledge-based, clinical conversation skills are developed through practice and experience during clinical skills teaching sessions. Among other challenges raised by the COVID-19 pandemic, pre-clerkship medical students lacked some of their only opportunities to learn the critical nuances of the art of effective communication with patients during the 2020-2021 academic year. While we have established creative ways to take most of our learning online, pre-clerkship medical students may be missing crucial experiences to develop skills at the very core of what makes a good physician.

Now third-year students across the country experienced an abrupt end to in-person clinical skills sessions beginning in March 2020, while many now second-year students had their very first patient interactions over video-conferencing platforms. As we learned the skills of expressing appropriate empathy, it has been difficult in many ways to display these multidimensional emotions through a two-dimensional screen. Even for those of us who have had experience with patient interactions in the past, we have noticed a stark increase in awkwardness in learners as well as Standardized Patients (SPs). Non-verbal actions that display empathy, such as touch, were no longer possible and left many of us unable and untrained on how to express empathy. It was challenging to read the intricacies of body language and create a welcoming and comfortable environment online, particularly when technological difficulties occur.

Below we provide some of our experiences as first- and second-year medical students in Ontario during the 2020-2021 academic year.

During one of our few in-person clinical skills teaching sessions, I recall instinctively placing my hand on the shoulder of the SP while adjusting my stethoscope to listen for the mitral valve. After the examination finished, the SP remarked: “Of all the things you did during this session, I really appreciate you placing your hand on my shoulder during the physical exam. It made me feel comfortable and showed that you care about me.” This taught me a valuable lesson about the importance of touch in providing empathetic care. While it seemed so natural in person, this is a difficult skill to learn or practice over virtual sessions. – Wafa Khoja

I recall a virtual session on ‘How to break bad news’ with an SP. Throughout our heartfelt conversation in which I told them about their terminal illness, I kept thinking to myself how I wished I could have held their hand or passed them a tissue box. Even though this was a simulated experience, I walked away shocked at the restraints that virtual platforms placed on my ability to deliver empathetic care. I especially found it difficult to gauge the patient’s emotions and read their body language through the screen, and as a result it became very hard to connect on a deeper, more humanistic level. – Shaishav Datta

Over time, as virtual care becomes the norm and we focus more on verbal communication, will we lose our ability to communicate non-verbally? Even now, as my classmates assess their SPs virtually, our communication styles are notably different from our senior colleagues. How will the under practiced skills of eye contact, body language, and reassuring gestures affect current pre-clerkship students in our upcoming training; clerkship and onwards?

Unfortunately, this concern regarding virtual clinical skills training is widespread. A December 2020 survey of second-year medical students at the University of Toronto showed that more than 50% of students did not feel that they had the necessary clinical skills needed to start clerkship.3 This feeling of unpreparedness was directly attributed to the virtual clinical skills curriculum due to COVID-19.3 Many expressed concerns regarding the skills they lacked relating to clinical encounters with patients, including expressions of empathy and compassion.

What is in store for this COVID-19 generation of physicians and how does it affect the profession as a whole? Non-verbal skills are mastered through practice and as an ensemble, comprise the underpinnings of a competent physician in the 21st century. They are qualities actively sought out by admissions committees that are now being omitted from teaching curricula because of the limitations of virtual medicine. During the COVID-19 pandemic, pre-clerkship students have been wholly excluded from in-person clinical settings for public-health reasons. Our lack of experience with expression of these emotions and the current way in which we are learning to communicate effectively through virtual means is likely to make the transition to clerkship difficult and uncomfortable for us and the patients we encounter. While we will hopefully recover and build these skills over the course of our training, it is prudent to consider the extent to which these forms of communication are being undervalued in virtual teaching.

We are grateful that medical school faculties have tried to provide pre-clerkship students with the best possible teaching and skills while adhering to public-health guidelines during the pandemic. Some schools adopted creative and expedited methods to deliver clinical skills training to students. For example, the University of Toronto offered an expedited preparation for clerkship “bootcamp” for current second-year students during the summer of 2021. Alternatively, Queen’s University created a system to permit limited in-person clinical skills sessions within small groups. Schools in other provinces across the country also developed strategies that are in compliance with the COVID-19 guidelines in their respective locations. Despite this, we ask you to consider: Is this enough? Will vastly online clinical skills training affect the ability of current pre-clerkship students to competently maneuver clerkship, residency, and future career? These are important questions that we as a medical community must consider to be potential side effects of the COVID-19 pandemic and must answer to prepare for future pandemics.


References

  1. Kelly M, Svrcek C, King N, Scherpbier A, Dornan T. Embodying empathy: a phenomenological study of physician touch. Med Educ. 2020;52(5):400-407. https://doi.org/10.1111/medu.14040
  2. Cocksedge S, George B, Renwick S, Chew-Graham CA. Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions. Br J Gen Pract. 2013;63(609):e283-e290. https://doi.org/10.3399/bjgp13X665251
  3. Kao J, Chan T. COVID FAQ Survey: A Review of Student Responses [unpublished data]. Toronto (ON): University of Toronto; 2020.

The role of the vOSCE in a post-COVID world

Ricky Tsang,1 Bailey Burrell1

1Faculty of Medicine, University of British Columbia, British Columbia, Canada


The emergence of COVID-19 has forced medical schools to adapt and re-imagine the delivery of curricular activities. Almost overnight, medical schools transitioned away from traditional, in-person instruction in favour of remote teaching to comply with public health orders. Digital technologies became paramount for the delivery of curricular activities and student assessment was no exception. Virtual Objective Structured Clinical Examinations (vOSCE) were developed and implemented at a rapid pace for the assessment of clinical skills.1,2 Thus far, they have been met with positive feedback from students and examiners.

Some studies posit that vOSCEs represent the future of clinical skills assessment. Proposed benefits include time and cost savings, adaptability and scalability, and comparability in scores between in-person and virtual examinations.2 Others maintain that in-person OSCEs remain the gold standard and should be reinstated once public health orders are lifted.1 We certainly agree that vOSCEs have merit in assessing history taking, counselling, and associated soft skills – the virtual platform lends itself well to their assessment. Our exposure to virtual care through primary care placements has reinforced the importance of developing these virtual care skills in an era where COVID-19 has catalyzed the growth of telemedicine. During the early stages of the pandemic, telemedicine represented between 38-77% of ambulatory visits in Australia, Canada, and the United States, and while reliance on this modality has declined with the relaxation of public health restrictions, use of telemedicine is projected to remain well above pre-COVID-19 levels.3 If it is the mandate of medical schools to train their students as well-rounded generalists, then developing and assessing their skills to conduct telemedicine-based, virtual patient encounters would appear indispensable as telemedicine is poised to remain integral to primary care in the post-pandemic world. This is also consistent with the eHealth-oriented CanMEDS competencies addendums proposed by the CanMEDS eHealth 2015 Expert Working Group, which suggest that the Medical Expert should be able to, “adopt a variety of information and communication technologies to deliver patient-centred care and provide expert consultation to diverse populations in a variety of settings.”4

Conversely, we believe the assessment of physical examination skills is ill-suited for the virtual format. Physical examination requires complex psychomotor skills and sensorimotor integration. Consider, for example, how impractical it would be to examine a baker’s capabilities through a virtual demonstration of their skill, without the opportunity to touch, smell, or taste their craft. Similarly, clinical skills are the “bread and butter” of a physician’s work and rely on aspects of the physical world that cannot currently be conveyed through a screen with any comparable degree of concision. Such an examination is neither practical nor feasible when assessed virtually, save for brief screening manoeuvres. That is why, when conducting telehealth appointments, physicians must recognize the limits of the appointment and arrange for in-person follow-up when necessary.5 Simply put, elements of a physical exam are lost when conducted virtually, and you cannot assess that which you have made impossible for students to perform. Likewise, students will be unable to receive feedback on important physical exam manoeuvres, many of which involve sensory feedback and nuance.

In an era where the physical examination is being eschewed in favour of medical technology that is increasingly relied upon for assessment and diagnosis, it becomes imperative to faithfully teach and assess physical examination skills to ensure future clinicians have robust competence in this dying art. The horse must remain in front of the cart – at least until the automobile that is medical technology becomes robust enough to replace it completely. Perhaps the solution in the meantime is one of compromise; the creation of hybrid OSCEs, one where in-person stations are utilized to assess the lion’s share of skills but are thoughtfully supplemented by virtual stations to assess the full spectrum of clinical skills required of the modern physician. It seems vital to us that physical exams remain physical, but that students are taught to incorporate the expanding number of options available to them for patient interaction.

Certainly, we do not mean to disparage the extraordinary efforts of medical schools that have adapted vOSCEs out of necessity and with great haste. The COVID-19 pandemic has affected life in a seemingly endless number of ways and forced the innovation of new paths forward. Perhaps too, it has catalyzed a new dawn in clinical skills assessment, one where physical and virtual skills are treated and examined as independent entities, but considered no less important than one another for the comprehensive education of a physician.


References

  1. Boyle JG, Colquhoun I, Noonan Z, McDowall S, Walters MR, Leach J. Viva la VOSCE? BMC Medical Educ, 2020; 20. https://doi.org/10.1186/s12909-020-02444-3
  2. Lara S, Foster CW, Hawks M, Montgomery M. Remote assessment of clinical skills during COVID-19: a virtual, high-stakes, summative pediatric objective structured clinical examination. Acad Pediatr, 2020; 20(6): 760–761. https://doi.org/10.1016/j.acap.2020.05.029
  3. Mehrotra A, Bhatia RS, Snoswell CL. Paying for telemedicine after the pandemic. JAMA, 2021: 325(5): 431-432. https://doi:10.1001/jama.2020.25706
  4. Royal College of Physicians and Surgeons of Canada. The CanMEDS 2015 eHealth expert working group report [Internet]. 2014. Available from: https://www.royalcollege.ca/rcsite/documents/canmeds/health-advocate-ewg-report-e.pdf [Accessed May 13, 2021].
  5. College of Physicians and Surgeons of British Columbia. Practice standard: telemedicine. 2020. Available from: https://www.cpsbc.ca/files/pdf/PSG-Telemedicine.pdf [Accessed May 13, 2021].

Junior medical students in a pandemic: an untapped resource

Aman Dhaliwal,1 Karlee Searle,1 Danielle Martin1,2

1Temerty Faculty of Medicine, University of Toronto, Ontario, Canada; 2Department of Family and Community Medicine, Women’s College Hospital. Ontario Canada


Globally, the COVID-19 pandemic has overwhelmed health care systems in an unprecedented way. There are far-reaching impacts, including in medical education.

In Canada, the increase in clinical demands led to changes in health care infrastructure, requiring physicians, residents, and senior medical students to step into new roles. This “all-hands-on-deck” approach was essential to pandemic response but has tended not to include junior (pre-clerk) medical students. How do we best utilize the skills of junior medical students in a pandemic or emergency situation when the existing frameworks do not accommodate this?

Junior medical students face a dilemma: they are well-equipped with the key attributes to become successful physicians but lack the necessary clinical skills to serve a meaningful role on the frontlines. In response, and despite a lack of official guidance, many junior medical students have forged their own role in supporting the community through various student-led initiatives. This experience has lessons to teach about how the medical student community can be marshalled in future emergency response initiatives.

As the COVID-19 pandemic progressed, it became evident that junior medical students had a strong desire to participate in pandemic relief measures. Despite the limited scope of their clinical abilities, Canadian medical students rapidly began uniting to establish community supports on a voluntary basis. Across Canada, over 150 student-led initiatives were started to assist the community and support frontline workers through the pandemic.1 Many of these initiatives shed light on the inequities faced by marginalized individuals in the pandemic and worked to mobilize community resources to better support these groups. For example, the COVID-19 Women’s Initiative focused on supporting women and gender minorities who experienced an increase in intimate partner violence during lockdown conditions in Canada. This group raised $30,000 and collected over 22,000 items for 35 women’s shelters across Canada in six months.2 Other junior medical student initiatives focused on partnering with seniors to address senior isolation, sourcing personal protective equipment, and assisting frontline workers with life tasks such as grocery shopping and child care.3 Undeterred by their inability to help on the frontlines, these students banded together to make a powerful impact in their communities. 

These medical student-led initiatives required students to augment and practise the CanMEDs competencies of advocacy, communication, collaboration, and leadership.4 Although the health advocate role is a core role of the CanMEDs competency framework, integrating health advocacy into medical school curricula has been challenging.5 One of many reasons for this may be time constraints with respect to teaching, illustrating, and responding to the social determinants of health.6 During the COVID-19 pandemic, time constraints for many pre-clerkship medical students were eased as curriculum requirements were either cancelled or moved to an online format. This may have opened up space for students to, in essence, build their own advocacy curriculum.

Medical programs that provide voluntary learning opportunities to work with underserved and marginalized groups allow students to better understand the social determinants that result in health disparities, as well as the ways in which health advocacy can be practically applied.7 These skills turned out to be important for short-term relief during a pandemic, and likely also for the long-term development of these future physicians.

While there are guidelines for ways that senior medical students can contribute to reducing the effects of the pandemic directly, there is a lack of guidance around the contributions of junior medical students. We propose three ways by which Canadian medical schools can facilitate junior medical student community involvement in pandemic and emergency situations.

First, medical schools can provide education and training to students regarding the wide range of non-clinical needs of a population during pandemics and other emergencies. Integrating disaster training into medical school curricula will increase student preparedness and improve knowledge and skills prior to a disaster.8 This training could point out the capabilities of junior medical students (as well as other junior trainees across nursing and health disciplines), to increase their sense of agency in disaster response.

Second, medical schools could provide curriculum flexibility in a pandemic or other emergency situation to allow students to engage in voluntary community support initiatives. Junior medical students who have been given the time and flexibility to pursue professional endeavours outside of the core curriculum exhibit increased productivity and sustained interest in their topic of choice.9 Furthermore, this flexibility alleviates the time constraints, which frequently act as a barrier to medical student engagement in advocacy work.

Lastly, a unified approach to the role of the junior medical student as part of “whole system response” can promote community engagement to all Canadian junior medical students. Current CFMS guidelines include a role for a pandemic response for senior medical students but neglect to provide a role for junior medical students. Further statements and guidance from national medical education bodies on Disaster Management Plans should expand their guidelines so that Canadian medical schools can prepare junior medical students to be active participants, living up to their full potential as people with time, energy, and a commitment to the health of their communities.10

Junior medical students are an untapped resource during emergencies like pandemics when the societal need for effectively diverting resources is at its greatest. We have a shared opportunity to further explore the ways in which junior medical students’ skills can be translated into meaningful community engagement during an emergency situation, and to accommodate this into established medical education frameworks. 


References

  1. Lu K, Schellenberg J. COVID-19 updates [Internet]. Canadian Federation of Medical Students. Available from: https://www.cfms.org/who-we-are/covid-19
  2. Parsons C. U of T med students assist women’s shelters during COVID-19 [Internet]. Faculty of Medicine. 2020. Available from: https://md.utoronto.ca/news/u-t-med-students-assist-womens-shelters-during-covid-19
  3. Bowden, S. COVID-19: Canadian medical students ready to step up. Univ Tor Med J. 2020;97(3):e8-e11.
  4. CanMEDS: Better standards, better physicians, better care. CanMEDS Framework. The Royal College of Physicians and Surgeons of Canada. Available from: https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e
  5. Hubinette M, Ajjawi R, Dharamsi S. Family Physician Preceptors’ Conceptualizations of Health Advocacy, Implications for Medical Education. Acad Med. 2014;89(11):e1502-e1509. https://doi.org/10.1097/ACM.0000000000000479
  6. Hancher-Rauch H, Gebru Y, Carson A. Health advocacy for busy professionals: effective advocacy with little time. Health Promot. 2019;20(4):489-493. https://doi.org/10.1177/1524839919830927
  7. Borouman S, Stein M, Jay M, Shen J, Hirsh M, Dharamsi S. Addressing the health advocate role in medical education. BMC Med Ed. 2020;20(1). http://doi.org/10.1186/s12909-020-1938-7
  8. Earnest M, Wong S, Frederico S. Perspective: Physician advocacy: what is it and how do we do It? Acad Med. 2010;85(1):63-67. https://doi.org/10.1097/ACM.0b013e3181c40d40
  9. Peacock J, Grande J. A flexible, preclinical, medical school curriculum increases student academic productivity and the desire to conduct future research. Biochem Mol Biol Educ. 2015;43(5):384-390. http://doi.org.10.1002/bmb.20875
  10. Cfms.org. 2021. [Internet] Available from: https://www.cfms.org/files/position-papers/2015%20CFMS%20Disaster%20Management.pdf

IMGs still ready, willing, and able to fight COVID-19

Malcolm M MacFarlane1

1Volunteer, Society of Canadians Studying Medicine Abroad (SOCASMA), Ontario, Canada

Back in April 2020, at the beginning of the pandemic, International Medical Graduates (IMGs) offered their services in the fight against COVID-19.1 Despite this offer, few IMGs have been inducted into the battle,2, 3 and hospitals and Long-Term Care homes continue to struggle with staff shortages.4

In an effort to assess continuing IMG interest in assisting with the pandemic in Ontario, the Society of Canadians Studying Medicine Abroad (SOCASMA) informally surveyed its members.

In less than a week, a total of 63 responses were received; 83% of respondents were resident in Canada, 63% were in Ontario, 92% of respondents were ready and willing to go to work in Ontario as Supportive Physicians and in other roles, and 43% of respondents indicate they would be glad to accept work in other provinces.

This potential workforce is well qualified with 92% already graduated from medical school; half of them having graduated in the past five years. A total of 62% are currently licensed to practice medicine in other countries, and 56% have practiced medicine in the past five years.

Why are we not making use of this valuable resource? Indeed, why does this valuable resource continue to be marginalized in the CaRMS (Canadian Residency Matching Service) residency match? Despite all applicants, including IMGs, being Canadian citizens or permanent residents, in 2020 about 2,000 IMGs5 were streamed to only about 325 IMG positions6 resulting in about a 16% match rate, while there were more residency positions for 3,000 Canadian medical graduates than there were applicants.7 In the 2020 Match, about 1,400 qualified IMGs who have demonstrated competence through objective examinations went unmatched, their skills and talents lost to Canadian society.7

A BC human rights complaint alleges that this is systemic discrimination based on place of origin. The SOCASMA survey lends some support to this argument. A total of 49% of respondents identified themselves as being visible minorities, 10% reported they were not visible minorities, and 40% did not respond. However, other indications suggest that many of the 40% who did not respond may well be invisible minorities so that up to 90% of IMG respondents may be visible or invisible minorities.

When we are struggling with a pandemic that has killed over 26,000 Canadians to date,8 when there is a humanitarian crisis in our long-term care homes,4 when five million Canadians are without a primary care provider when existing health care providers are rapidly becoming exhausted and ill themselves, it is shameful that we are ignoring and marginalizing the valuable resource that IMGs represent.

As the Canadian Medical Association’s recent Policy on Equity and Diversity in Medicine9 states, it is time to open “the conversation to include the voices and knowledge of those who have historically been underrepresented and/or marginalized” and to ensure “that everyone has equal and inherent worth, has the right to be valued and respected, and to be treated with dignity.” “Equity in the medical profession is achieved when every person has the opportunity to realize their full potential to create and sustain a career without being unfairly impeded by discrimination or any other characteristic-related bias or barrier.”

Excellent words! It is past time we in Canada were true to the values of equity we espouse.

References

  1. Villan M. ‘We want to join this fight’: immigrant physicians make plea to serve on front lines of Covid-19.  CTV News, April 30, 2020 Available: https://calgary.ctvnews.ca/mobile/we-want-to-join-this-fight-immigrant-physicians-make-plea-to-serve-on-front-lines-of-covid-19-1.4881919 [Accessed June 17, 2021].
  2. Atlin J. Covid-19 and Canada’s underutilized internationally educated health professionals. World Education News and Reviews, October 29, 2020. Available: https://wenr.wes.org/2020/10/covid-19-and-canadas-underutilized-internationally-educated-health-professionals [Accessed June 17, 2021].
  3. Desai D. Where are Ontario’s internationally trained doctors in its Covid-19 response? National Post, February 8, 2021. Available: https://nationalpost.com/news/where-are-the-internationally-trained-medical-professionals-in-ontarios-pandemic-response [Accessed June 17, 2021].
  4. Casey L. ‘We still have an acute staffing shortage,’ Ontario’s long-term care commission hears. Global News, October 16, 2020. Available: https://globalnews.ca/news/7400847/ontario-long-term-care-homes-staffing-shortages-coronavirus/ [Accessed June 17, 2021].
  5. 2020R-1 Main Residency Match – first iteration Table6: Applicant pool by school of graduation. CaRMS. Available: https://www.carms.ca/wp-content/uploads/2020/05/2020_r1_tbl6e.pdf [Accessed June 17, 2021].
  6. 2020R-1MainResidencyMatch-first iteration Table14: Dedicated quota offered to IMG applicants by discipline. CaRMS  Available:  2020_r1_tbl14e.pdf (carms.ca) [Accessed June 17, 2021].
  7. 2020R-1 Main Residency Match Table1: Summary of match results.  CaRMS. Available: 2020_r1_tbl1e.pdf (carms.ca) [Accessed June 17, 2021].
  8. Government of Canada. Covid-19 daily epidemiology update Government of Canada. Available: COVID-19 daily epidemiology update – Canada.ca [Accessed June 17, 2021].
  9. Equity and diversity in medicine. Canadian Medical Association. December 2019. Available: https://policybase.cma.ca/en/viewer?file=%2fdocuments%2fPolicyPDF%2fPD20-02.pdf#phrase=false [Accessed June 17, 2021].

Tackling the gender gap: the need for group-based mentorship programs

Noam Raiter,1 Ana Hategan2

1Michael G. DeGroote School of Medicine, McMaster University, Ontario, Canada; 2Department of Psychiatry & Behavioural Neurosciences, McMaster University, Ontario, Canada

The number of female medical students in North America has outweighed that of males in recent years, and at a quick glance, it may seem like we have achieved equality in the medical field.1 Females in medicine continue struggling to meet their male colleagues in academic promotion, producing scientific journal articles, and obtaining leadership positions.2,3

The root of this disparity lies in what is known as the “Hidden Curriculum,” a powerful education process that takes place beyond the traditional classroom and yet shapes the field of medicine in its entirety.4 The hidden curriculum ingrains social norms, stereotypes and values from the beginning of medical school, influencing decisions about specialty, family balance, and pursuing leadership positions.5 The medical field may not deny women access to any of these achievements, but the hidden curriculum inherently discourages them.

Medical students need to learn that these stereotypes and social norms are based on nothing more than bias. Thus, we must provide female medical students with strong female role models.

Receiving mentorship from senior professionals allows juniors to form the connections and frameworks needed for ongoing success.2 Mentorship is a critical part of medical education and career progression, but the forms and mechanisms in which it exists vary widely in accessibility and efficacy. Thus, we propose the introduction of consistent female to female mentorship programs in medical schools across Canada.

Three mentorship models have the strongest usage: the dyad model, the multiple-mentor model, and the peer-mentor model. The most traditional of these is the dyad model in which one senior mentors one junior.5 This model is generally successful but not without flaws. Lack of female mentors remains a significant barrier.3 This makes it possible for some female medical students to have successful dyad mentorship, but others to be left without guidance. This imbalance of mentors to mentees is likely due to two main factors. First, the current rise in female matriculants has created more mentees needing mentors. This barrier is likely to adjust over time as we continue to promote new females in medicine to pursue leadership and research careers. Second, the hidden curriculum deters women from obtaining these positions and thus they cannot serve as mentors. Women are found to be clustered within certain specialities with lower remuneration that are known to promote “good work life balance.” Even within specialties, a gender wage gap is consistently demonstrated.6 Another flaw of the dyad model is that sometimes a singular mentor is not able to provide all the necessary expertise and connections needed for a mentee’s specific career goals. For example, if a medical student is interested in exploring both surgery and physician wellness, they may need two separate mentors with expertise in these two areas. Especially due to the limited number of mentors, it is not certain a junior will be able to find a senior mentor with their exact career goals. Due to these reasons, other models have been trialled.3

With the multiple-mentor model,  a mentee seeks multiple mentors to address different aspects of their journey.5 This model addresses the issue of needing multiple mentors to cover all future aspirations as discussed in the above example. On the downside, the multiple mentor model does not address the low availability of female mentors and if anything, augments that barrier by requiring multiple mentors per mentee. However, this model in some cases may allow for a lower time commitment for mentorship and allow mentors to take on multiple mentees.

A third model, the peer-mentor model, has also been cited as successful in previous studies.3 This model promotes females of similar rank to work together toward a common goal, meaning that medical students and junior physicians would serve as each other’s mentors and help connect each other with opportunities and education. Such a model specifically tackles the barrier of accessibility and, despite being quite different than traditional ideas of junior-senior mentorship, has been shown to still provide some value to career progression.5  However, it is not able to entirely compensate for the expertise and networking opportunities provided in traditional senior to junior mentorship models such as the dyad and multiple-mentor models.

Clearly, mentorship is important but existing models fall short in meeting the needs of females in medicine. Thus, we propose the implementation of a novel approach, Group-Based Mentorship, which may provide all the important benefits of mentorship while tackling barriers. This model consists of a group of multiple mentors and multiple mentees. This model provides increased accessibility, addresses needs of multi-passionate students, and fosters junior-senior mentorship. Group-based mentorship also contributes unique value in that it can allow for multidirectional streams of information transfer which allows mentors to also learn from their younger mentees. This is important as traditional mentorship models such as the dyad or multi-mentor model intrinsically promote a hierarchical relationship and thus dissuade the mentor from learning from the mentee. In contrast, a group-based program promotes mentorship through a collective of females and will thus help strip away any power dynamics and provides additional benefit to senior professionals by allowing juniors the opportunity to introduce modernized and innovative perspectives of medicine. Recently, numerous journal articles have pointed towards the need of a cultural shift and continued feminist movement within the medical field.7,8 Further, statistics show that despite consistent efforts to revamp wellness of medical students and physicians, burnout rates have not fallen and suicide remains the only cause of death higher in physicians than the general population.9,10 Medical students and young trainees are entering medicine at a time of a paradigm shift and therefore bidirectional discussion and information transfer can help facilitate this much needed change. Additionally, as technology continues to take on a larger role in medicine,11 mentees can aid their mentors in remaining creative and innovative in their practice. All in all, this will ensure the successful progression of medicine in all of its facets.

Thus, we pose the need for female group-based mentorship programs across Canadian medical schools in order to stride towards true gender parity and begin to invoke a critical paradigm shift in medical culture. Group-based mentorship will help ensure that female physicians continue to progress, thrive, and make meaningful contributions to the field of medicine in the coming decades. Future work should aim for the development of specific frameworks to guide the formation of group-based mentorship programs. Such frameworks will aid seamless adoption of such programs in Canadian universities and ensure equal access to all female medical students in Canada.

References

  1. Association of Faculties of Medicine of Canada (AFMC). TableG-1. In Canadian Medical Education Statistics 2018 (40th vol, pp. 137). (2019). Ottawa, ON: AFMC. https://afmc.ca/sites/default/files/pdf/CMES/CMES2018-Complete_EN.pdf. [Accessed August 2, 2020].
  2. Hategan A, Bourgeois JA, McConnell, M. Gender gap: A cross sectional study of academic departments. Journal of Psychiatry Reform. 2016;2(2).
  3. Farkas AH, Bonifacino E, Turner R, Tilstra SA, Corbelli JA. Mentorship of women in academic medicine: a systematic review. Journal of General Internal Medicine. 2019;34(7):1322-1329. https://doi.org/10.1007/s11606-019-04955-2
  4. Phillips CB. Student portfolios and the hidden curriculum on gender: mapping exclusion. Med Ed. 2009;43(9):847-853. https://doi.org/10.1111/j.1365-2923.2009.03403.x
  5. Mayer AP, Files JA, Ko MG, Blair JE. Academic Advancement of Women in Medicine: Do Socialized Gender Differences Have a Role in Mentoring? Mayo Clinic Proceedings. 2008;83(2):204-207. https://doi.org/10.4065/83.2.204
  6. El Jaouhari S. The ongoing need for feminism in medicine. Can Med Ed J. 2020.
    https://doi.org/10.36834/cmej.71053
  7. Hardouin S, Cheng TW, Mitchell EL, et al. RETRACTED: Prevalence of unprofessional social media content among young vascular surgeons. J of Vasc Surg. 2020;72(2):667-671. https://doi.org/10.1016/j.jvs.2019.10.069
  8. AlShebli B, Makovi K, Rahwan T. RETRACTED ARTICLE: The association between early career informal mentorship in academic collaborations and junior author performance. Nature Communications. 2020;11(1). https://doi.org/10.1038/s41467-020-19723-8
  9. Vogel L. Even resilient doctors report high levels of burnout, finds CMA survey. CMAJ. 2018;190(43). https://doi.org/10.1503/cmaj.109-5674
  10. Schernhammer E. Taking their own lives – the high rate of physician suicide. New England Journal of Medicine. 2005;352(24):2473-2476. https://doi.org/10.1056/NEJMp058014
  11. Mitchell M, Kan L. Digital technology and the future of health systems. Health Systems & Reform. 2019;5(2):113-120. https://doi.org/10.1080/23288604.2019.1583040

Telemedicine as an enabler of success: revisiting the undergraduate medical curriculum

Neel Mistry,¹ Paul Rooprai,¹ Stefan de Laplante,¹

¹Faculty of Medicine, University of Ottawa, Ontario, Canada

Telemedicine has grown substantially since the advent of the COVID-19 pandemic. As global cases surged in March 2020, hospitals and primary care clinics quickly turned to telemedicine – the provision of medical care using telecommunication technology over a virtual platform – to increase access to safe and effective patient care.1 Among US medical schools, an increase in telemedicine training in clerkship has been reported over the last five years.2,3 In contrast, only one medical school in Canada includes a formal telemedicine program in the undergraduate medical curriculum.4 As COVID-19 cases continue to surge across the country, the need for medical trainees to achieve competence in telemedicine is crucial. In this paper, we provide an overview of the benefits and challenges of formalizing telemedicine training and discuss steps that Canadian medical schools can take to successfully implement this change.

The future of healthcare

Telemedicine is not yet formalized in the undergraduate curriculum at most Canadian medical schools and very few include it in post-graduate training. In stark contrast, over 25% of US medical schools include telemedicine training in pre-clerkship, and nearly half offer mandatory sessions in clerkship.2 Recently, Wayne State University conducted a pilot study in which third-year medical students were introduced to telemedicine during their core internal medicine rotation.2 The results were encouraging, with 95% of clerks acknowledging the importance of virtual care services and more than 80% considering it to significantly affect their future practice.2 Similar findings were reported at Harvard Medical School, which instigated telemedicine training in clerkship at the start of this pandemic.5 Why, then, is Canada lagging behind when there are just as many reasons, if not more, to promote virtual care as there are south of the border?

An early introduction to telemedicine and virtual care provides multiple educational advantages to medical trainees. Aside from contributing to core competencies in patient care, clinical knowledge, and practice-based learning, it also fosters a greater sense of familiarity, preparing students for a practice where telemedicine is used and may be growing. This can be done in multiple ways. First, asynchronous learning can occur by creating videos that demonstrate how to perform physical exams virtually and allowing clerks to shadow their attending physician via video. Second, visiting electives that were originally suspended for the 2020-2021 cycle can still take place in a virtual format. This would allow students to diversify their clinical experience and, at the same time, help them decide which institution they would like to attend for post-graduate training. Finally, telemedicine can be included in core clerkship rotations such as family medicine, internal medicine, and surgery. Doing so would provide students with opportunities for independent practice while experiencing an array of topics including ethical dilemma, telemedicine-based cases, teleassessments, and procedural skills.

A call to action

The COVID-19 pandemic has instigated unprecedented change across healthcare settings. With hospitals and clinics rapidly shifting to virtual care, a few undergraduate medical programs have begun to implement virtual care; however, training must be formalized across all Canadian medical schools. An early introduction to virtual care offers numerous benefits to trainees as the use of telemedicine grows. This can be done in three main ways: (1) incorporating virtual shadowing opportunities, (2) re-instituting visiting electives via a virtual format, and (3) integrating students into virtual patient consults during clinical rotations. With COVID-19 accelerating the adoption of telemedicine, the need to prepare future doctors to deliver care virtually has never been greater.

References

  1. Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health 2020; 20:1193. https://doi.org/10.1186/s12889-020-09301-4
  2. Waseh S, Dicker AP. Telemedicine Training in Undergraduate Medical Education: Mixed-Methods Review. JMIR Med Educ. 2019;5(1): e12515. https://doi.org/10.2196/12515
  3. Jumreornvong O, Yang E, Race J, Appel J. Telemedicine and Medical Education in the Age of COVID-19. Europe PMC. 2020; 95(12):1838-1843. https://doi.org/10.1097/acm.0000000000003711
  4. Aires LM, Finley JP. Telemedicine activity at a Canadian university medical school and its teaching hospitals. J Telemed Telecare. 2000;6(1):31-35. https://doi.org/10.1258/1357633001933916
  5. The Harvard Gazette. The mother of invention, 2020 [Internet]. Available from: https://news.harvard.edu/gazette/story/2020/05/harvard-medical-school-uses-telemedicine-as-a-way-forward/ [Accessed December 30, 2020].

La pandémie de COVID-19 affecte-t-elle votre ouverture d’esprit ?

Does the COVID-19 pandemic affect your mindset?

(English translation below)

Dr Alexandre Lafleur,1 Mme Claudie Michaud-Couture,2 et Dre Miriam Lacasse3

  1. Professeur agrégé de clinique. Département de médecine, Faculté de Médecine, Université Laval, Québec, Canada. Co-titulaire de la Chaire de leadership en enseignement en pédagogie des sciences de la santé AMC-MD
  2. Assistante de recherche. Département de médecine, Faculté de Médecine, Université Laval, Québec, Canada
  3. Professeur agrégée. Département de médecine familiale et de médecine d’urgence. Faculté de Médecine, Université Laval, Québec, Canada. Co-titulaire de la Chaire de leadership en enseignement en pédagogie des sciences de la santé AMC-MD

Ressentez-vous de l’anxiété ou de la frustration lorsque vous sortez de votre zone de confort? Êtes-vous démotivé lorsqu’un collègue ou un supérieur vous donne une rétroaction? Ruminez-vous pendant des heures lorsque vous n’avez pu atteindre le résultat escompté?

Si vous avez répondu « oui », vous êtes davantage sujet à adopter une position de fermeture face aux apprentissages (fixed mindset en anglais)1. Ne craignez rien, en prendre connaissance est déjà une partie de la solution ! En tant qu’étudiant, résident et médecin, vous avez fort probablement vécu des expériences qui vous ont confronté à vos limites physiques, émotionnelles ou intellectuelles. En pareilles situations, vous avez avantage à adopter un état d’esprit d’ouverture face aux défis à relever (growth mindset)1. Vous apprendrez plus, tout en ayant un plus grand sentiment d’accomplissement et de contrôle.

Miser notre réussite uniquement sur notre performance apporte un grand sentiment de réalisation lorsque les résultats convoités sont obtenus. Toutefois, face à l’échec nous vivons des frustrations.  L’estime de soi, la motivation et le plaisir d’apprendre diminuent2. D’autant qu’en médecine, les résultats échappent souvent à notre contrôle. Bien que cela soit appelé à changer, les études médicales nous outillaient peu sur la résilience face à l’erreur ou l’échec3. L’erreur n’indique pas que nous ne sommes pas intelligents. C’est signe qu’il faut continuer de se perfectionner.

Un esprit fixe croira que l’intelligence et les talents ont tout à voir avec la chance; ces dés qui ont été lancés à la naissance. Que si vous n’arriviez pas à jouer des accords à la guitare, réussir votre intubation ou encore rassurer adéquatement un patient endeuillé : « Ce n’est pas fait pour moi, je n’ai pas ce talent ». Vraiment? Le défi est-il une menace à notre intelligence? Une personne qui vise à accroitre ses savoirs dans un état d’ouverture d’esprit vous répondra : « Je ne sais effectivement pas faire cela, pas encore »1.  L’échec et les remises en question les atteignent, mais sans toutefois les définir. Ils demeurent pragmatiques. Ils ne croient pas devenir exceptionnels dans tout, mais certainement meilleurs, avec le temps et les efforts.

Traduit et adapté de Dweck CS1 par les auteurs

Bien qu’elle ne soit pas à balayer du revers de la main, une méthode pédagogique qui met uniquement l’accent sur l’évaluation de la performance mène les apprenants à se juger et à se comparer, amenant son lot de stress. D’ailleurs, nous sommes exposés à un environnement compétitif parfois depuis nos premiers pas : « Tu marches trois mois plus tôt que ta sœur! » La performance de l’un est récompensée au détriment des efforts de l’autre. Or, Carole Dweck, professeure à l’Université Stanford, a démontré que les enfants qui apprenaient à valoriser uniquement la performance plutôt que l’effort, délaissaient les buts d’apprentissage à long terme.2 Le risque est de vouloir sembler performant aux yeux d’autrui plutôt que de devenir réellement compétent.4

Au cœur de cette pandémie, où chacun doit sortir de sa zone de confort, c’est l’occasion idéale de réagir positivement aux nouveaux défis et de les aborder comme des opportunités d’apprentissage. Ce n’est pas le temps de conserver des pensées fixes qui nous incitent à croire que nous allons échouer, que nous ne sommes pas assez qualifiés ou encore que notre intelligence sera minée.

Certaines notions vous manquent? Vous doutez de vos compétences? Changez votre mentalité et considérez cette occasion unique d’apprendre et d’aider. Essayez, lorsqu’un défi se présente, de considérer l’opportunité de devenir meilleur, plutôt que de croire que vous n’êtes pas en mesure de le relever. Profitez des critiques et des commentaires pour vous améliorer. Félicitez les efforts de vos collègues et redoublez d’ardeur pour atteindre encore plus de qualifications.

Vous pouvez aider vos étudiants et collègues à accroitre leur ouverture d’esprit.5 Ciblez vos rétroactions sur le processus plutôt qu’exclusivement sur le résultat. Formulées sous forme de questions, vos rétroactions laisseront place à la discussion : « connais-tu une autre manière de faire? ».  Donnez-leur l’opportunité d’initier eux-mêmes les moyens à mettre en œuvre et appuyez leurs efforts.4 Créez un climat de travail positif dans lequel votre entourage se sentira à l’aise de demander conseils, sans peur d’être jugé.

Nous espérons qu’en terminant la lecture de ce texte, vous penserez : «  Je ne suis pas toujours ouvert d’esprit … pas encore, mais j’ai hâte d’y travailler ! »


Do you feel anxious or frustrated when you go outside of your comfort zone? Are you feeling down when a colleague or superior gives you feedback? Do you grumble for hours when you have not been able to achieve the desired result?

If you answered “yes”, you are more likely to adopt a fixed mindset1 towards learning. Don’t panic, learning about it is already part of the solution! As a student, intern and doctor, you most likely have had experiences that challenged your physical, emotional or intellectual limitations. In such situations, it is to your advantage to adopt a growth mindset1 position to face the challenges that lie ahead. You will learn more, while having a greater sense of accomplishment and control.

Betting our success solely on our performance brings a great sense of accomplishment when the desired results are achieved. However, when confronted with failure, we experience frustration. Self-esteem, motivation and the pleasure of learning diminish.2 Especially since in medicine, results are often beyond our control. Although this is bound to change, medical studies have given us little insight into resilience when dealing with error or failure.3 Error does not mean that we are not smart. It is a sign telling us that we need to keep improving.

A fixed mindset will believe that intelligence and talent have everything to do with luck; those dice that were thrown at birth. That, if you can’t play chords on the guitar, succeed an intubation or adequately reassure a bereaved patient: “This is not for me, I don’t have that talent.” Really? Is the challenge a threat to our intelligence? Someone who aims to increase his or her knowledge in a growth mindset attitude will answer: “I don’t really know how to do this, not yet.1 Failure and questioning affects them, but without defining them. They remain pragmatic. They do not believe they will become exceptional in everything, but certainly better with time and effort.

Adapted from CS Dweck1 by the authors

Although it does not have to be brushed aside, a teaching method that focuses solely on performance assessment leads learners to judge and compare themselves, bringing its share of stress. In fact, we have been exposed to a competitive environment sometimes from the very start: “You’re walking three months ahead of your sister!” One person’s performance is rewarded at the expense of the other’s efforts. But Carol Dweck, a professor at Stanford University, has shown that children who learn to value performance rather than effort only, neglect long-term learning goals.2 The risk is to want to appear to perform well in the eyes of others rather than to become truly competent.4

In the midst of this pandemic, where everyone has to get out of their comfort zone, this is an ideal opportunity to react positively to new challenges and approach them as learning opportunities. This is not the time to hold fixed thoughts that lead us to believe that we will fail, that we are not sufficiently qualified or that intelligence will be undermined.

Are you missing any notions? Do you have doubts about your abilities? Change your mentality and consider this unique opportunity for you to learn and help. Try, when faced with a challenge, to consider the opportunity to become better, rather than believing that you are not up to it. Take advantage of criticism and feedback to improve yourself. Praise the efforts of your colleagues and work harder to achieve even more qualifications.

You can help your students and colleagues to increase their growth mindset.5 Focus your feedback on the process rather than exclusively on the outcome. Your feedback should be in the forms of questions, and should include a discussion: “Do you know another way to do this?” Give them the opportunity to initiate the means to implement themselves and support their efforts.4 Create a positive work environment in which those around you feel comfortable asking for advice, without fear of being judged.

We hope that when you finish reading this post, you will think: “I’m not always open-minded… not yet, but I look forward to working on it!”

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Empowering Canadian Medical Students with Financial Literacy: The Financial Transition to Practice Group

Shaishav Datta, Sabrina Fitzgerald, Wafa Khoja, Harrison Watt, Alain J. Azzi

alain.azzi@mail.mcgill.ca

Conflicts of interest: The authors are all Financial Transition to Practice (FTP) Ambassadors at their respective institutions. Funding: There is no source of funding.

Medical training in Canada requires many years of commitment to develop skills necessary for effective patient-centered care. However, there is more to a successful practice than diagnosis, treatment, and pathophysiology. Today, many early-career physicians find themselves unprepared for the complexities of the personal and professional financial decisions they must make on a daily basis, even with hired assistance.1 These include understanding billing systems, insurance plans, tax policies, accounting, investments, debt management, and other financial decisions associated with starting a new practice. Research shows that most early-career physicians learn about financial literacy from their peers or through independent research.1 Formal education on financial literacy remains minimal while the process of learning these skills concurrent to making a transition to practice provides undue stress and is implicated in contributing to early-physician burnout.1,2

Further, medical learners accrue significant personal financial burden as a direct result of the cost and length of their training. This is especially reflected in trainees who pursue longer residencies and fellowships, as they continue to work at a lower income level than they would make if they had entered practice directly. Many studies have suggested that medical learners have low personal financial literacy and are not well prepared to manage their own finances.3

Thus, while the Canadian medical education system prepares its trainees to become world-class clinicians, it falls short in equipping graduates with the skills to navigate the complexities of personal and professional finance. To address this issue, basic financial literacy must be introduced early, during medical school, and extended into residency training as they approach independent practice.

Over the last decade, various organizations have initiated programs that serve to contribute towards financial literacy in medical learners. Table 1 provides a brief overview of some national-level resources (Table 1). Available upon request.

Table 1. Various platforms for trainees to learn about basic personal and professional finance.

  1. Canadian Medical Association (CMA): https://www.cma.ca/physician-wellness-hub/topics/personal-finance Practice management topics from Joule and MD Financial Management
  1. Canadian Federation of Medical Students (CFMS):https://www.cfms.org/resources/finances/ Financial planning and education provided by MD Financial Management and CFMS, insurance discount information, free tax filing services.
  1. Federation of Medical Women of Canada (FMWC): https://fmwc.ca/resources/mdfm/ Written resources, tools, and calculators for medical students, residents, practitioners, and retirees provided by MD Financial Management.
  1. Association of American Medical Colleges (AAMC): https://aamcfinancialwellness.com/index.cfm Financial Wellness resource provides courses, individualized recommendations, and tracking tools in an independent manner.

While these resources are useful, they are often created and supported by commercial organizations that stand to gain benefit from their users. This often leads to unanswered questions regarding conflicts of interest causing medical trainees to remain distrustful of the information provided by these sources.1 Additionally, teaching financial skills using non-interactive modalities makes it difficult for learners to engage with and apply their knowledge, leading to poor long-term retention and application of the information.4 While single interventions understandably improve short-term behaviors, we believe financial literacy education should be provided through comprehensive tutorials that are incorporated at key points of contact with students, from on-boarding to financial aid disbursement to exit counseling. In this way, the importance of responsible financial decision-making is reinforced over time.4

Medical institutions recognize this gap, and many are developing financial curricula to address these challenges. As an example, the Temerty Faculty of Medicine, University of Toronto has incorporated ~10 hours of dedicated didactic and interactive module-based learning over the academic year. However, there is currently a lack of national standardization of the content, resulting in discrepancies in access to the same educational quality.

The Financial Transition to Practice (FTP) group was established with the hopes to mitigate the aforementioned gaps in knowledge. It is a grassroots initiative, currently functioning through a social media platform, aimed at increasing awareness and knowledge to medical students across Canada. Since its debut in early October 2020, over 1800 Canadian trainees have joined the group, validating the interest medical students have in enhancing their financial literacy. At the core of the group are student leaders acting as ambassadors for each of the seventeen Canadian medical schools. By providing knowledge, we hope to empower medical students to gain confidence and autonomy over their finances and related decision making. Current membership is free of charge and all content is non-sponsored to ensure minimized conflicts of interest.

Informational content presented through the group has included live question and answer sessions hosted by both rural and urban professionals that directly addressed inquiries made by group members. Recorded webinars regarding basics of accounting and debt management through the continuum of training have been shared. Webinars that allow for interactive versions of basics of investments and insurance, incorporation, shareholder agreements, buying a practice, financial ethics, and practice management are in development. These are examples of high-yield financial literacy topics the group hopes to share with members, as literature shows it is beneficial to be familiar with such topics prior to transitioning into practice.1,3 Through this national effort, we hope to mitigate gaps in current medical education in order to assist Canadian medical students to transition into practice with the necessary financial knowledge and strategies needed to be autonomous, informed, and proficient practitioners.

References
1. Bar-Or YD, Fessler HE, Desai DA, Zakaria S. Implementation of a Comprehensive Curriculum in Personal Finance for Medical Fellows. Cureus. 2018;10(1):e2013. https://doi.org/10.7759/cureus.2013
2. West CP, Shanafelt TD, Kolars JC. Quality of Life, Burnout, Educational Debt, and Medical Knowledge Among Internal Medicine Residents. JAMA. 2011;306(9):952–960. https://doi.org/10.1001/jama.2011.1247
3. Comber S, Crawford KC, Wilson L. Competencies physicians need to lead – a Canadian case. Leadersh Health Serv (Bradf Engl). 2018;31(2):195-209. https://doi.org/10.1108/lhs-06-2017-0037
4. Lujan HL, DiCarlo SE. Too much teaching, not enough learning: what is the solution? Adv Physiol Educ. 2006;30(1):17-22. https://doi.org/10.1152/advan.00061.2005

Medical School, Going Virtual

Aazad Abbas
University of Toronto

Burnout among healthcare professionals has been extensively documented.1 In their piece titled “Physician Burnout, Interrupted”, Hartzband and Groopman⁠ shed light on how sweeping changes in healthcare systems have led to unprecedented rates of burnout among physicians in recent decades.2 Fundamentally, their perspective is widespread implementation of electronic health record (EHR) systems and performance metrics have eroded the intrinsic motivation of modern physicians.3

Hartzband and Groopman present compelling arguments dissecting how the core pillars supporting professionals’ intrinsic motivation and psychological well-being – autonomy, competence, and relatedness – have eroded over the last half century.4 Autonomy has disappeared through constant surveillance. Competence was replaced by checking off boxes. Relatedness is threatened by a system increasingly driven by money and metrics. These changes represent a shift to extrinsic factors becoming the dominant motivating force among modern physicians. They argue this is the very reason why burnout is almost a universal experience among medical professionals, from budding medical students to veteran physicians.

From the shift to evidence-based medicine in the 1900s, to the invention of one of the most successful surgical procedure in the modern times – the hip arthroplasty – medicine has been at the forefront of innovation.5 Medical practitioners are constantly integrating scientific discoveries with technological innovations to bring forward the next revolution in healthcare. Except this time an unforeseen natural threat has forced us to adapt medical practice: COVID-19. Medical schools shifting their curricula online; clerks having countless rotations cancelled; residents being moved to unplanned services; physicians scrambling to take care of their patients. These are just a handful of ways in which medical professionals have adapted to the pandemic, willingly or otherwise.
With these changes, it is important to ask how these changes affect the experiences of medical students. Medical school is a time of immense change, as you cram to study as many topics as possible, learn a plethora of skills rotating through all specialties, and home in on your professional skills. This training camp of medical school is made bearable through the sense of bonding with peers, as you all traverse this together. At least that was true until very recently. The motivation of students across the globe has plummeted, with a generalized sense of uncertainty for the future.6

No more shadowing, no more scrubbing in for the first time, no more going to lecture with your colleagues. Medical institutions have gone above and beyond in ensuring the medical school experience is maintained as much as possible. However, the recent pandemic has stolen valuable opportunities for medical students, eroding their intrinsic motivation. 6 Passing courses and meeting assignment deadlines have become the primary factors pushing students. Asides from the hopes of returning to normal once a vaccine is delivered, students have lost their drive for learning. This loss of drive, combined with an overarching sense of anxiety about the future, chips away at the feelings of belonging. It seems like there is no light at the end of this tunnel.

How does one repair the damage done? Is it the responsibility of medical schools to motivate students? Is it the responsibility of the friends and family to urge students not to give up? Or is the responsibility of the medical community as a whole to recognize and repair every crack in the system? Fixing the damage starts with looking at one’s self. Being a medical student is a privilege, something most medical students have worked hard to achieve. Due to the demands of medical school, this is something easily forgotten. Students should remind themselves why they went to medical school in the first place. Why they have chosen to walk this long and arduous path. Each student has their own motivations for pursuing medicine, from the death of close relatives to the drive to reduce systematic racism in medical institutions. These reasons speak to the deeply personal intrinsic motivations of medical professionals. At the end of the day, medical professionals seek to better the lives of others. Remembering this core tenant of medicine is the only way we may seek to keep our passion thriving, for everything around us seems to be on fire.

It is time for medical students to adapt to the current climate of uncertainty. To address the issue of burnout, and to continue innovating into the future, medical students need to adapt to this reality. This pandemic is an opportunity to bring about the change desperately needed in medicine. The way medicine will be practiced, the shape of the Canadian healthcare system, and the very status of physicians in society will be shaped by this generation of medical students.

aazad.abbas@mail.utoronto.ca

References
1. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016. DOI: 10.1016/S0140-6736(16)31279-X.
2. Hartzband P and Groopman J. Physician Burnout, Interrupted. N Engl J Med 2020. DOI: 10.1056/nejmp2003149.
3. Friedberg MW, Chen PG, Van Busum K,R., et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Rand Health Q 2014.
4. Gagné M and Deci EL. Self-determination theory and work motivation. J Organiz Behav 2005. DOI: 10.1002/job.322.
5. Knight SR, Aujla R and Biswas SP. Total Hip Arthroplasty – over 100 years of operative history. Orthop Rev 2011. DOI: 10.4081/or.2011.e16.
6. Bentata Y. The COVID-19 pandemic and international federation of medical students’ association exchanges: thousands of students deprived of their clinical and research exchanges. Medical Education Online 2020. DOI: 10.1080/10872981.2020.1783784.