The role of the vOSCE in a post-COVID world

Ricky Tsang1, 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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