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.

Uncertainty, over-cautiousness and assumptions: How clinical reasoning got crushed during the COVID-19 pandemic

Even our wildest nightmares in the earlier months of the year wouldn’t have hinted about the incalculable magnitude of the loss we are facing in postgraduate training. Our confidence that the virus wouldn’t cause much havoc in tropical countries like India shattered like bad crystal falling unceremoniously upon the wood floor and the vogue lock-down dramatically reduced the number of teaching cases for months on end.

Our bedside learning teaching activities suddenly transitioned into online domains where the nuances of skills training was equated with hours of SOP / guidelines monologue and slowly we started disorienting ourselves from our reasoning abilities as well. Uncertainty is not uncommon in postgraduate residency and we could say that experts etch themselves out of diagnosing ill-defined or vague features. But the uncertainty surrounding this pandemic is something we have never encountered before.

The flexibility of the iterative diagnostic process was compromised because both patients and authorities weren’t intentional enough in tolerating uncertainty. Everyone had their own sense of urgency and bounded rationality. Patients and their supporters were concerned about the social stigmatization in the earlier months and so were concealing crucial parts of their histories. In subsequent months, emphasis was levied on prescribed pathognomonic pattern of disease and this lead to representative bias. The pressure to diagnose COVID-19 circumvented the basic need of asking the simple things like a history of exposure to allergens in the living room. Even an experienced clinician decides to take a swab the moment he developed an irritation in his throat. Such is the level of ‘anchoring’ induced by the disease incidence and prevalence.

Why so? Why have we conveniently ignored the hard-earned and reliable reasoning skill at time of this pandemic? Why could we not intentionally reason or self-explain or hypothetically-deduct when reality confronts us? Simple. Our training was more on certain grounds and the cases used for our training were grounded in contextual factors. We reason well when we stay emotionally composite and follow a well-practiced structural paradigm of case solving. Encountering multiple independent variables in an emotionally vulnerable dilemma forces us to adopt intuitive reasoning and a reductionist coping strategy. This wasn’t learned in conventional clinical reasoning sessions where we simply solved narrowly designed case vignettes without much emotional distractions or contextual noise.

What’s next? The pandemic outbreak is a clear example of ‘disorienting dilemma’ in the field of clinical reasoning. It has transformed our way of thinking and obviously, the way clinical reasoning has been conceptualized. We don’t know when we shall be rid of COVID-19 as a diagnosis at hindsight and start reasoning in analytical fashion as before. As the days pass by, the fear of contracting the disease from random patient encounter also escalates and this indeed might increase the dis-junction and cognitive fatigue.

We have been taught that clinical reasoning and decision making are not a bed or roses. It is indeed a bumpy road of handling tensions, navigating uncertainties, learning from failure and not succumbing to cognitive biases lurking in our brains. But, we could not deny the fact that post-graduate residencies all over the world have suffered a worst hit during this time of pandemic and unlike other turmoil, we don’t have a hint about the salvage point. The only thing at our hands is using the uncertainty to shape ourselves and develop adaptive expertise of decision making in the “new normal” ward settings.

Dr. Dinesh Kumar, Assistant Professor, Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Dr. Shuriya Prabha, Postgraduate resident, Department of Paediatrics, Rajah Muthiah Medical College, Tamil Nadu, India

Personal development during the pandemic: an online journey for a faculty member

‘The coin’ was an excellent idea. Most other participants seemed to agree. We were attending an online workshop on Team-based learning (TBL) as part of the faculty development activities at the International Medical University in Kuala Lumpur, Malaysia. We were using the Microsoft Teams platform and following the plenary were working on an actual TBL case in small groups of five or six faculty members. We completed the individual readiness assurance test (IRAT) before joining our groups and were now working through the group readiness assurance test (GRAT). We discussed the correct answer in our group, arrived at a consensus regarding the same and now scratched the card to reveal the correct answer. It was a tense moment. An electronic coin was available to maneuver to scratch the card and reveal the correct answer. We received immediate feedback on our choice. If the choice was incorrect, the group discussed further before choosing the next option. As the marks obtained decreased with each wrong choice, we were cautious and guarded. It was a lesson on how assessment can provide immediate feedback on learning
Small group learning (SGL) sessions for large number of students using a single facilitator can be conducted using TBL. The workshop provided me with a good working knowledge about TBL and its theoretical underpinnings. I interacted with and got to know other faculty members and educational technology staff at the institution.
I had completed all formalities to join the IMU Centre for Education at the International Medical University in Kuala Lumpur, Malaysia but was not able to physically join as the corona virus pandemic exploded on the world scene in mid-March. All travel was closed and most countries were under lock-down. In the pre-internet era, the old adage ‘Out of sight out of mind’ would have been very true. In today’s world, the internet allowed me to stay in touch with my new colleagues and interact with them.
I participated in the Centre meetings and the online workshops and had a good overview of the activities of the Centre. The sudden shift to online learning at the University required a lot of support to be provided to faculty members by the IMU Centre for Education (ICE). I did not yet have access to the learning management system (LMS) and an institutional e-mail. My colleagues were kind enough to help me with material as and when required. In some ways my personal situation was similar to the King Trishanku in Indian mythology. Due to the pandemic (and the availability of modern information technology) I was suspended midway between my new job and colleagues and my present location at my parental home in Mumbai, India. I interacted with my colleagues online and participated in some of the activities and deliberations. However, I could not yet contribute fully to the activities of the center. I was not present fully in either location and felt suspended in between the two worlds. Trishanku wanted to enter heaven in his physical, mortal body. He obtained help from the sage, Vishwamitra who using his spiritual powers transported him to heaven. The Gods were alarmed and the King of the Gods, Indra pushed Trishanku back down toward earth. The sage used his powers to arrest Trishanku’s fall and he was suspended upside down midway between heaven and earth. The sage created a new heaven for Trishanku where the king resided in his mortal body.
I participated in other online learning sessions and workshops on writing cases for problem-based learning sessions, using Zoom for online sessions especially the break out rooms feature for small groups, using Articulate storyline and a session on aligning program educational objectives and program learning outcomes. The key learning point for me was not confining the measurement of learning outcomes to the conclusion of the educational program but moving forward and relooking the outcomes after the graduate has worked at a job for a few years. I felt this was a useful concept as it also considered the impact of learning on the job on learning outcomes at the time of graduation.
I also attended a mandatory workshop on the fundamentals of teaching-learning for all new faculty. The workshop was from 9 am to 5 pm and the time difference between India and Malaysia meant I had to start early. Doing a daily eight-hour session entirely online for three days was a novel experience for me, the other participants and the resource persons. Working together with faculty members from pharmacy, nutrition, dentistry, Chinese medicine and other areas provided me with an understanding of teaching-learning in these areas. We worked on aligning learning outcomes and teaching-learning methods and creating assessments based on the learning outcomes.
The ‘virtual’ small group activities were an important learning point for me as an educator. I had facilitated many small group sessions face-to-face but doing the same online was a new experience. Sharing screens, documents, interacting through audio and video and collaborating on a task was a rich learning experience. The two commonly used platforms Zoom and Teams both have the option of creating breakout rooms. The facilitator/s could move between rooms providing support and guidance when required.
The major personal impact of the pandemic was a reminder by Nature of human frailty and vulnerability. After the second world war, medicine had impressive success against infectious and communicable diseases. With antibiotics, improved sanitation and vaccination most infections were no longer the monsters they once were. The medical curriculum and the media started focusing more on chronic diseases. Investment in antimicrobial drugs declined. Many nations still had weak public health systems and did not invest enough on health. The recommendation that at least 5% of the budget should be invested on health and another 5% on education was not followed. I read about the Spanish flu and the massive death toll but like most others wrongly believed that we in the modern brave new world were immune to the ancient plagues. I was afraid especially when neighbors in our apartment building tested COVID-positive and relieved when they were discharged from treatment facilities without complications. I believe we may need to provide infectious diseases, antimicrobials, epidemic control and prevention their rightful place in the curriculum.
The lock-down had a major impact on economic activity. As academicians we often debate whether we can shift learning and assessment totally online. I think we may have to see the bigger picture. Even today economic activity cannot take place optimally without face-to-face interaction and free movement of people. For some time, we may be able to enforce movement restrictions but in the longer-term economic catastrophe is inevitable. With economic hardships funding for education will likely slow down with a serious impact on universities and colleges.
We live in a very uncertain time. For me, the pandemic and the subsequent lock-down has created a roller coaster of emotions. I feel privileged to contribute to the center for education, work and collaborate with like-minded colleagues and participate in training and education sessions but sad and concerned about the COVID-19 pandemic, the lock-down, travel restrictions, the possible collapse of an old way of life and the delay in physically joining my colleagues and taking up the new assignment. I am also certain that medical education will not be the same post-pandemic and technology and blended learning approaches will play an increasingly important role. Face-to-face lectures for large groups of students may become much less common. Scientists predict with climate change and increased population growth, the potential for pandemics is going to increase. So, their early detection and containment may be the key to human survival. Often, I think it ironic that as human beings we expend so many resources and so much time and effort on devising better ways of killing each other being oblivious of the microscopic assassins lurking all around us!

P Ravi Shankar
IMU Centre for Education
International Medical University
Kuala Lumpur, Malaysia.

Matching to a pandemic

In early March my classmates and I were packed like sardines into a bar, all of us wearing the same white t-shirt. Words like “Western”, “Gen Surg”, “UBC”, “Family”, and in my case “Toronto” and “Emerg” scrawled hastily on the front. Ecstatic at having matched, coronaviruses, social distancing, and PPE could not have been farther from our minds.

This scene is inconceivable now, especially as the final few weeks of our medical school careers were abruptly cancelled with an email one Thursday evening. No one thought that our final lecture would be a sparsely attended affair on herbal medicine, that we would be receiving our degrees by courier instead of on a stage, or that many of us won’t see each other again before residency begins. I am fortunate to be in the privileged position of having my future residency training position secured, of having a safe place to live, and of having money to pay for the essentials. These elements give my mind the opportunity to wander, to consider the bizarre space that those of us in this position now inhabit. Aside from a few thousand dollars in fees paid to a variety of organizations with four-lettered acronyms, I am exactly as competent (or incompetent) today as I will be on July 1st. The difference will be that on that day I will take on the mantle of ‘resident’ and be expected to jump headfirst into whatever the world looks like from the doors of the emergency department at whatever hour my first shift begins.

I am excited, and more than a little scared, about this moment. I’m anxious to be able to do something tangible to help more experienced practitioners (read: everyone) provide care to the never ending parade of humanity that arrives at the hospital doors every day. With recent news of senior medical students being called to begin residency early, perhaps that day will come sooner than expected, although I sincerely hope it does not come to that. But the fact remains that the past four years have conditioned us to always be on the lookout for a way to help the team. The famous last words of every medical student’s day are, after all: “Is there anything else I can help with?”

So, what can I, and those like me, help with? Of course, staying physically distant from others, scrubbing my hands like my attending is watching, and supporting friends and family who may not be as fortunate. Medical students across the country have organized to provide childcare, collect much needed PPE, and check in on seniors, the goal being to lift even a tiny amount of stress from healthcare workers stretched thin. We are constantly on the lookout for ways to serve, and many classes have reached out to health authorities to lend a hand wherever and whenever we might be useful. But my mind continually jumps ahead to the first of July.

Two months ago, none of us could have imagined that our match would coincide with this once-a-century pandemic. Instead of being concerned with finishing classes, celebrating with family and planning for that treasured pre-residency vacation, I am left with a gnawing anxiety. Memories of Match Day, that now seem to have been formed in a different era, have been displaced by questions about what all of us brand new PGY1’s be walking into. Will I be a burden or have the capacity to help? How will our excitement to begin our chosen specialties meld with the weariness of those who have been on the front lines of this pandemic since Day 1? How can I make the most of this newfound time? And so, we read and learn, stress and relax, hoping to be ready to dive in and help whenever we can. Until then, you’ll catch me here, >6 feet away from anyone else.

James Riggs

The “Heart” in Medical Education is Distributed

by Manish Ranpara

Distributed Medical Education (DME) is the concept of diversifying the experience of students across cultures, communities, borders and hearts. Yes hearts – it is an addition to the definition that you will not find anywhere but it is arguably the most important.

The parts of medical education: The head represents education, the heart represents formation, and the hands represent training.

The benefits of students gaining different experiences during training are multiple. Canada is a vast and has a heterogeneous population with different needs. Training learners in remote communities teaches them about the needs of the communities and how they can be better addressed. The knowledge can be passed on and be used to improve the health of the local population.
In the special edition of CMEJ, Brown and colleagues describe an innovative program, where theatre was used to advocate the needs of the local homeless population and educate healthcare professionals. DME allows for a greater immersion and therefore appreciation and understanding of local healthcare needs in underserved areas, and this can result in the learner gaining valuable clinical and non-clinical skills. The medical program at the Northern Ontario School of Medicine (NOSM) is one of Canada’s success stories for DME. Strasser and colleagues tell us how community engagement is crucial to the university’s socially accountable curriculum. They explain the various hats of community engagement at NOSM such as participation in the medical student admission process.
Medical students often do not know which specialty they would like to enter. Gaining varied experience through DME helps budding clinicians make more informed decisions about future career choices. However, there is an argument that students placed in remote regions do not get adequate exposure to some medical specialties and “cutting edge” innovation because these tend to be more centralized in urban areas. Jattan et al. elaborate this issue further in the special edition of CMEJ. They found family medicine residents in rural locations had fewer teaching opportunities than their urban counterparts. This can potentially hinder and discourage residents and physicians with an interest in academics pursuing a career in rural Canada.
DME has many benefits, and all medical universities in Canada integrate DME in their curriculum to some extent. The social accountability of the medical profession has gained significant momentum in recent years and universities are on board to train physicians today to address the needs of Canadians today and tomorrow. Several steps have been taken to bridge the gap for example more money has been invested in recruiting and retaining rural physicians and training programs have been revised to be more socially accountable. Still, plenty of work needs to be done as several regions and communities within Canada lack ample healthcare professionals, and health inequalities remain unacceptably high. What else can be done to address the needs of underserved communities?

Dr. Manish Ranpara trained at Cardiff University, UK. After working as a doctor for 2 years in England, he immigrated to Canada. He was involved in research at the University of Calgary, and he is currently a family medicine resident affiliated with the University of Toronto. You may find him in an exercise class, reading a classic,  or singing his heart away (earplugs not provided).

Is medical education app-happy?

There’s an app. for that!

Dr. Manish Ranpara

I was recently browsing my mobile’s application store for applications to help me prepare for my upcoming medical examinations. I was rather surprised (and pleased!) to see a vast array of medical applications available on the market. Applications for drug calculations, anatomy demonstrations, pathology quizzes and clinical case studies were among the many applications available to download at the click of a button.

Medical education was once largely a pedantic, classroom based endeavor. Over the years, it has evolved significantly to become the multidimensional model we know today. Universities from around the world employ several methods of teaching, from classic large group lecturing and small group tutoring where physical presence is required, to virtual classrooms and online lectures where students can learn from a remote coffee shop. Some universities have even tapped into the mobile application craze and offer some services such as recorded lectures through them.

Apart from student and physician education, medical applications have found their way into the pockets of patients. Several exist to help the general population understand and treat their disease better; from applications which track glucose monitoring in diabetics to applications which provide cognitive behavior therapy for depression.

While it is humbling to see the progression of medical education through the digital era,  it does raise some concerns. The internet and indeed the application world remains a largely unregulated domain. Consequently, a lot of questionable material exists in this brave new virtual world. Ethical dilemmas include the following: Can and should a doctor be allowed to create a medical application which has the capacity to reach millions of users including the general public without the application undergoing peer review? Is it acceptable to provide medical education for free using technology when enrollment to a university is required to obtain a degree? What codes of practice apply to research done through mobile applications and virtual enrollment? These are all interesting and complex questions which we should try to answer as we venture to the unknown world of tomorrow, armed with a stethoscope and a mobile phone/computer.

As we rapidly advance through the digital age (where politicians and business leaders are debating artificial intelligence), it is crucial for our profession to keep pace with the exciting and challenging changes of technology. While I believe that a greater investment in digital understanding should be made by stakeholders in the medical field it is also vital to support patient safety by leading the way in setting regulations and standards for the dissemination of medical information exploding through the proliferation of commercial apps. It’s never been more appropriate to say: ‘There’s an app. for that’ – but is it a good one?

Dr. Manish Ranpara trained at Cardiff University, UK. After working as a doctor for 2 years in England, he immigrated to Canada. He was involved in research at the University of Calgary, and he is currently a family medicine resident affiliated with the University of Toronto. You may find him in an exercise class, reading a classic,  or singing his heart away (earplugs not provided).

CMEJ Vol 7 No 2 hot off the press (so to speak)

This issue of the CMEJ contains several very interesting studies exploring a range of topics and groups.elephant

I want to expand on what Danilewitz and colleagues found when asking about incorporating leadership training into residency education: There’s no time!  This is the elephant in the room that no one wants to address or confront, but which takes up space and makes us all behave in ways so as not to rile the beast. Let me translate to make this perfectly clear: “there’s no time” really means there are other topics and activities of higher priority. “They are busy” means they have more important things to do, sorry.  So what is more important than leadership training, point of care ultrasound, transgender and sexual minority health, exercise prescription, and more emphasis on clinical decision-making? Most everything we already do, it seems; medical education is an organism without an excretory system all bound up in tradition.

Marcus Law and colleagues start us off in the dark and murky world where social media and professional expectations mingle with “Exploring Social Media and Admissions Decision-Making – Friends or Foes?” Their study explored social media in Canadian undergraduate admissions, and the attitudes of admissions personnel towards such use. A sizeable proportion of admissions personnel had at some point examined social media profiles to acquire information on applicants. There seems to be an ethical vacuum, and participants expressed significant apprehension based on concerns for fairness and validity. What happens in admissions stays in admissions?

“Attitudes of Canadian Psychiatry Residents If Mentally Ill: Awareness, Barriers to Disclosure, and Help-seeking Preferences” by Tariq Hassan et al. show that the medical culture defined by mental illness stigma, non-disclosure, and avoidance of professional treatment – like a good zombie – just won’t die! One third of their respondents (psychiatry residents at all levels) admitted to a personal history of mental illness. Frequent barriers to disclosure included stigma, career implications (more stigma?), and professional standing (which sounds like stigma yet again).  How many orthopedic residents would tell a friend they had a broken leg before going to see a surgeon for fear their career might be negatively affected by their rather obvious, unsightly, and debilitating cast?

Liao, a medical student when he wrote “Entitlement and Me: Problems in Canadian Medical Education,” shows a rare, deep, and penetrating acuity.  He tells us that the idea that he was special was cultivated (and drilled into him – my words) by, no less, the faculty of his medical school. And this happens across the country. What were we thinking?  The barely subtle message has some not so subtle negative consequences, as Sylvia Cruess and her team point out in a commentary on Liao’s letter, not the least of which is a loss of altruism, a core value of any profession but especially medicine.

In “Physician Recruitment and Retention in New Brunswick: A Medical Student Perspective,” Mariah Giberson and her team explore physician recruitment and retention from the medical students’ viewpoints. The 158 medical students who completed the online survey indicated that job availability for both the medical student and the partner were the top factors when deciding where to practice. We wonder if that is a regional effect and challenge other researchers to find out (then let us know).

Jerry Maniate and his team in “Supporting clinician educators to achieve ‘work-work balance’” highlighted the many tensions clinician educators face in balancing the sometimes competing demands of clinical, education, research and administration tasks.  You will have to read their paper to discover the “Four Ps” that support clinician educators’ performance and productivity through work-work balance.

Marlon Danilewitz et al. in “A Landscape Analysis of Leadership training in Postgraduate Medical Education (PGME) Training Programs at the University of Ottawa” showed that, while there is some agreement on the importance of leadership skills and training in postgraduate education, the “no time” excuse shows that there are other far more pressing priorities. Who will identify the elephant in the room?

“Point-of-Care Ultrasound as a Competency for General Internists: A Survey of Internal Medicine Training Programs in Canada” by Jonathan Ailon et al. found that, while three quarters of internal medicine trainees and over half of General Internal Medicine faculty used point of care ultrasound clinically, the vast majority of residents and two thirds of faculty had received little or no training, an obvious discrepancy pointing to a clear need. How far behind practice will training lag?

In “Addressing Gaps in Physician Knowledge Regarding Transgender Health and Healthcare through Medical Education,” McPhail and colleagues wrote about the high rates of discrimination and related illnesses suffered by transgender persons (those persons whose sex at birth does not “match” their felt gender identity) due, in large part, to the denial of care by physicians. Interviewing both physicians and trans people, they found transphobia and a lack of physician knowledge as reported both by trans people and by physicians resulted in a denial of trans-specific care. They recommend trans health topics be included in medical education curricula.

Solmundson et al, in “Are we adequately preparing the next generation of physicians to prescribe exercise as prevention and treatment?” asked why few physicians provide exercise prescription in spite of the myriad benefits.  Surveying UBC family medicine residents, they found (with a spectacular response rate of over 80% (319/396), that more than 95% felt prescribing physical activity would be important in their future practice while rating themselves “somewhat incompetent.” There appears to be a clear need here!  Medical school curriculum committees and post-graduate program directors take note!

Wen Tay et al, in “Systems 1 and 2 thinking processes and cognitive reflection testing in medical students” used the simple Cognitive Reflection Test (CRT) to measure the ability of 128 medical students to activate metacognitive processes and switch to System 2 (analytic) thinking where System 1 (intuitive) thinking might mislead them. Ten percent of students chose the intuitive but incorrect answers to all three questions, suggesting those students generally relied on System 1 thinking.  Approximately 44% of respondents answered all three questions correctly, indicating full analytical, System 2 thinking. While CRT performance may not predict their future expertise as clinicians, the test may be a useful educational exercise in helping students to understand (1) the importance of regulating their thinking when they do get out into clinical practice, and (2) that they should not believe everything they think.

Desrosiers and her co-authors have given us a timely study, “Curricular Initiatives that Enhance Student Knowledge and Perceptions of Sexual and Gender Minority Groups: a Critical Interpretive Synthesis”. With no accepted best practice for helping students learn to care for sexual and gender diverse groups, they set out to synthesize the relevant literature using a modified Critical Interpretive Synthesis. From thirty-one articles, they found that the multi-modal strategies that encouraged awareness of one’s lens and privilege in conjunction with facilitated communication seemed the most effective. They add that to move forward theoretically and practically we will need to draw on both the wider cultural competence literature and the sexual and gender diversity literature. Perhaps there is some phronesis for us all in their modest conclusion: helping our students with their formation, education and training may take a multi-model mentored approach to curriculum design and implementation.

“Learning-by-Concordance (LbC): Introducing undergraduate students to the complexity and uncertainty of clinical practice” by Fernandez and his team described the problem of the steep learning curve in early clerkship. The gap between pre-clerkship course content and the reality of clinical decision-making expected in clerkship can make your head spin. Deer caught in the headlights, anyone? The Learning-by-Concordance approach can bridge this gap by providing expert responses that students compare with their own, expert explanations and key-messages. The authors concluded that expert panel answers and explanations can contribute to the development of appropriate professional reasoning processes. But of course, the same could be said of many other practical application focused curricula. What’s stopping us from focusing more on clinical decision making? One barrier is the prevailing belief in medical education that students not only need but must be buried by truckloads of scientific facts before they can be trusted to learn even the basics of clinical decision making. There are a lot of elephants in that room or perhaps just one very large immutable and immoveable mammoth!