Social Media & Medicine


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A Publication For Medical Students in Ontario

Vol. 9, Issue 3 – September/14

Social Media & Medicine P18

Clerkship Teaching Methods: Understand the how and why of crucial teaching modalities used by preceptors

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What kind of doctor do you want to be?

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How to tackle the difficult question every medical student has to answer

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EDITORIAL By Soniya Sharma, Queen’s University, Med Class 2015 Marianne J. Stroz, Queen’s University, Med Class 2016 Co-Chairs, Ontario Medical Student Association

Welcome to a new year of medical school! As you

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begin to get settled into medical student life, we hope you’ll enjoy this expanded issue of Scrub-In, which TRAVE L

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Before we get into the details of this issue we’d like to draw your attention to the banner above. For the fourth consecutive year, Scrub-In has been honoured with the Hermes Creative Award in the publications category from the Association of Marketing and Communication Professionals. This is a prestigious honour for the publication, and our many contributing medical student writers! The cover theme for this issue — how to engage social media both personally and professionally — is an important topic facing medical students. Digital media specialist Raman Singh gives practical advice and tips for medical students in Social Media and personal branding: should you get an early start in medical school? on page 10. We also have a

detailed look at Twitter’s usefulness for medical students on page 12, where University of Ottawa students Andrew Micieli and Brittany Harrison, and Dr. Alireza Jalali, explore this media giant’s role in the lives of health care professionals. We have two articles on the important topic of specialty selection: Western University’s Kevin Dueck, who examines The hidden curriculum and the unspoken culture of medicine and specialty, on page 20; and University of Toronto’s Scott Turcotte tackles the question every medical student is asked: What kind of doctor do you want to be?, on page 22. This issue also features an interview with physician leader Dr. Liisa Honey, chief of obstetrics and gynecology at Queensway Carleton Hospital, on the

topic of work/life balance in Opening doors and forging a new career path, on page 4. The various teaching methods used during clerkship can sometimes be intimidating for medical students. University of Ottawa’s Natasha Larocque looks at the importance of these methods, as well as how and why they are used, in An overview of the different methods used in clerkship training, on page 18. Finally, the annual Scrub-In Readership Survey is now underway. This survey provides valuable information so we can continue to improve and deliver a high-quality publication to Ontario medical students. The survey only takes five minutes to complete, and can be accessed at www.oma.org/Scrub-In.

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Managing Editor Matthew Radford Copy Editors Elizabeth Petruccelli Kim Secord Jenny Cheadle Raman Singh Karan Vashist Hao Shi ISSN 1923-953X www.oma.org / www.omsa.ca

Publisher’s Notes Scrub-In is published three times a year by the Ontario Medical Association 150 Bloor St. West, Suite 900 Toronto, Ontario, M5S 3C1 Tel. 416.599.2580 or 1.800.268.7215 Fax 416.340.2232 Email: [email protected] Opinions expressed in articles are the opinions of the authors and do not imply endorsement by the Ontario Medical Association. Scrub-In is distributed to all student members of the Ontario Medical Association.

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Scrub-In reserves the right to edit submissions. Material in Scrub-In may not be reproduced in whole or in part without the written permission of the OMA. Requests for reprinting or use of articles should be forwarded in writing to the OMA Public Affairs Department, c/o the Managing Editor.

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Vol. 9, Issue 3 – September 2014

Leadership

Opening doors and forging a new career path: an interview with physician leader Dr. Liisa Honey By Virve Aljas, OMA Engagement and Program Delivery

Leadership skills are an important tool to help physicians explore career options and opportunities beyond traditional practice. The Physician Leadership Development Program (PLDP) is one of the many offerings from the OMA to help physicians reach their leadership potential and become engaged in the transformation of the health care system. Driven by their desire to enact change, many of the PLDP graduates have gone on to spearhead and develop innovative projects in their communities. One such graduate is Dr. Liisa Honey, chief of obstetrics and gynecology at Queensway Carleton Hospital in Ottawa, and medical director of the maternal newborn program. In this interview with Scrub-In, Dr. Honey offers her insights on physician leadership, women in medicine, work/ life balance, and how small, communitybased health initiatives can lead to largescale change in the health care system. Scrub-In: How did you become involved with the PLDP? Dr. Honey: I hadn’t planned on a career in leadership, and as with many physician leaders I’ve heard from, you get nominated into leadership positions. I heard about the PLDP from a colleague who had been in the first cohort. I realized how it could open doors for me, so I applied. Scrub-In: In the past, and outside of your career, did you gravitate toward leadership roles? Dr. Honey: Yes. I think other people saw that potential in me more than I did. I was Chair of the Junior Members Society at the Society of Obstetrics and Gynae-

cology of Canada. I do gravitate toward positions where I can effect change. Scrub-In: Tell me about your experience with the PLDP. Dr. Honey: Many people who get into the PLDP have specific goals in mind. I went into the program not really having a plan, but it changed my career path. Coming out of the program, I was very focused on where I wanted to go next. I developed a higher level of self-awareness, enhanced my communication and negotiation skills, and learned how to effectively function within a team. I became acutely aware of what my strengths and weaknesses are, and I try to play to my strengths. The networking opportunities that this program presented were huge for me, especially with respect to women in the program. There is a real dearth of women in leadership positions, and I was one of the women thinking, “I can’t do that.” I felt I couldn’t juggle my career, family and everything else. Connecting with other women dealing with the same issues, making the same sacrifices, was enlightening. Scrub-In: How can we better motivate women to get involved in leadership roles? Dr. Honey: Mentoring women and en4

couraging them to take on leadership roles is critical, because the leadership styles of men and women can be very different. One of the things I hope to do is to become a mentor to other women looking at taking on a position of leadership. Women make up 50% of medical school enrolment and there is a need for more role models out there. Male colleagues can support their female colleagues by encouraging more women to become part of the team. The more women see other women in leadership roles, the more likely they are to join in. Scrub-In: Did you have mentors that helped to guide your specialty or career choices? Dr. Honey: I’ve had many mentors over the years. Some were specialty-specific, and many of them taught me how to balance family and career. Now my mentors are physician leaders who are looking at health care reform. Scrub-In: Why did you specialize in obstetrics and gynecology? Dr. Honey: I enjoy the technical skills required for OB/GYN, and the variety of work keeps things interesting — alternating from the office to the operating room, to labour and delivery. Vol. 9, Issue 3 – September 2014

Scrub-In: This is a women’s health specialty that has been historically dominated by men. Has this changed?

Scrub-In: What is the main skill that you took away from the PLDP? What do you use the most on a daily basis?

Dr. Honey: Now this specialty is dominated by women. Our challenge in OB/ GYN is going to be keeping the men interested. We need a mix of men and women to maintain balance and help move forward with the changes in health care that lie ahead.

Dr. Honey: Communication. I thought I was a good communicator before, but I’ve learned how to be more effective in getting my message across. Additionally, it’s confidence. Prior to the program, I would never have had the confidence to tackle these issues. It gave me a basis, background, and credibility to move forward with a lot of these initiatives.

Scrub-In: The PLDP culminates with a final project, and yours focused on work with C-sections. You mentioned earlier that you didn’t have a clear goal in mind at first, so was this topic something you were already involved in? Dr. Honey: This is where serendipity comes into play. During the first couple of months in the program, I was focused on a different topic altogether. Then I came across an article looking at Eastern Ontario and our C-section rates. My coaching group pointed out that I lit up when I talked about the changes that should be made. I realized that this was where my passion lies, and it became my new focus. I completely changed gears. My passion continues to grow. I’m proud of the way our culture has changed within our department. Everyone has become aware of the issues and that we have to change our practice. I’m hoping it becomes a prototype for our Local Health Integration Network (LHIN), and that we take it further. My next step in leadership is to get involved in our LHIN and scale up this project even more.

Scrub-In: If I had asked you 10 years ago, “Where do you see your career heading?,” how might you have answered? How has your perspective changed? Dr. Honey: I would have seen myself with a comfortable OB/GYN practice. Now, I see my career trajectory changing and I am taking on new roles and challenges. I don’t like to be comfortable. Instead, I prefer taking on new risks and moving into areas that require more learning and training. Scrub-In: How would you advise medical students — both male and female — about timing family or other significant life events alongside their careers?

Dr. Honey: Just do it! There is no ideal time, and there will always be juggling and sacrifice. Career and family are both important, and they are not mutually exclusive. There will be times when one or the other will require more focus, but then you find the balance again. Scrub-In: Why is it important for physicians to look beyond their practice? Why should they care about leadership initiatives? Dr. Honey: Medicine is changing. Physicians need to be a voice in how to move the health care system forward in a way that works for both providers and patients. This will require compromises on both sides. Physicians add a unique perspective to high-level discussions and can help to shape policy. They need to be a louder political voice when it comes to health care reform. Scrub-In: Is there anything else you would like medical students to know? Dr. Honey: Medicine is what you make of it. Sometimes the right fit for you isn’t immediately obvious but is stumbled upon later. There are so many opportunities to explore.

Scrub-In: Do you see this initiative as something that could be implemented provincewide? Dr. Honey: I haven’t thought that far ahead, but it could become a priority. This started with a very similar approach at a hospital outside of Toronto. We’ve been able to modify it so that it works with our population, which is critical, because every population is different. Changing the culture you work in is not just about the physicians, it’s also the allied health professionals, the management team, and the patients, and includes patient education and patient expectation. All of these are considerations.

Dr. Liisa Honey camping in Glacier National Park, British Columbia, with her family. “There is no ideal time [to have kids], and there will always be juggling and sacrifice,” says Dr. Honey. “Career and family are both important, and they are not mutually exclusive.” 5

Vol. 9, Issue 3 – September 2014

FEATURE

Win a $150 voucher to help with a trip home, moving, or a cellphone bill

Balancing empathy and discernment: reflecting on a first-hand learning experience By Priya Sivarajah, Western University, Med Class 2016

my first real student experience was in the emergency department, where I was shadowing an Ear, Nose and Throat resident who had been called in to manage a potential peritonsillar abscess. I was looking forward to seeing an abscess outside of the lecture hall, but Little did I know I would be learning a lot more. We entered the cramped room, where I took a seat behind the resident. The patient — a middle-aged woman — was very clearly in pain, rocking back and forth with her mouth slightly open. In stark contrast, the patient’s husband was jovial, appearing to compensate for his wife’s disposition. The resident began by noting the patient’s relevant medical history, which she answered to the best of her ability. Due to the abscess, it was as if her mouth was full of cotton balls and her pain was quite visibly impairing her ability to form words or communicate intelligibly. The extent of her pain became clear when the resident began the physical examination. As medical students, we are prepared extensively for difficult and/or emotional patients. In that context, I have only ever seen a standardized patient cry. There was something very genuine about this patient’s pain that left me speechless, and almost impatient for her to receive her treatment in order to relieve her pain. I was so consumed by these thoughts, that I almost didn’t hear the resident’s diagnosis: it was not a peritonsillar abscess, but most likely a case of tonsillitis. When the resident left the room to dictate the case, and order some laboratory investigations, I followed him. I could see that something was troubling him, and he explained that the patient’s pain was disproportionately extreme considering her diagnosis of tonsillitis. Upon speaking with the nurses, there was suspicion of an ulterior motive pertaining to

drug-seeking behaviour. Upon hearing this, I found myself speechless. I trusted the experience and knowledge of these trained health care professionals, but found it hard to reconcile with the overwhelming empathy I had felt just moments earlier. This created a mixed bag of emotions, largely of betrayal, embarrassment, and confusion. I began having thoughts that bartered with what was happening: perhaps there had been a mistake, an error in judgment? Or, perhaps the patient was hyper-sensitive to pain. Despite these thoughts, I could tell that I had experienced a change personally. My demeanour and approach became different. As I listened to the resident update the patient and her husband, I realized that I was starting to scrutinize their actions and their words, searching for any indication that would confirm the suspicion. I noticed too that I was perceiving any and every potentially innocent question in a different light. The patient was prescribed antibiotics, and while the patient was still offered some pain medications, I learned in my post-call talk with the resident that I cannot let my personal opinions about the patient interfere with my professional conduct. Due to my inexperience, I still find the line is blurry. My advice for others in similar positions is to follow your senior’s lead and always refer to your senior before making decisions where this uncertainty exists. This is the same advice my preceptor gave in a small group class as well. 6

That night, I replayed the entire experience over in my head, failing to find any obvious clues that would have suggested something other than a patient who was truly in pain. I found it alarming how quickly my view had changed, and was confused as to whether that was even an appropriate response to the situation. The importance of understanding the patient’s feelings and ideas has been reinforced countless times in my experience of medical school. From what I could discern, the resident’s opinions did not affect his care, but is that a reasonable expectation in all scenarios? In addition, should I have been swayed so easily, when I could not discern for myself what it was that would have led me to the same belief? This was an important educational experience for me, and made me wary of potential consequences of something as straightforward as prescribing pain medication. We’ve learned in school how Ontario is the leading province in Canada for narcotic use per capita. There are evolving guidelines on prescribing opioids, which are a prominent issue in medical education and practice. This experience taught me that applying these guidelines in real-life patient encounters is something that takes experience given the often ambiguous nature of patient presentations. In this situation, it was the resident’s knowledge of the diagnosis, and his previous experience, that spoke to the fact the patient’s behaviour wasn’t in keeping with the diagnosis. Vol. 9, Issue 3 – September 2014

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Feature

Altitude: Healthcare Mentoring the importance of mentoring undergraduate students By Alexander Whelan, University of Ottawa, Med Class 2016, Josh Kandiah, University of Ottawa, and Brooke Raycraft, Wilfred Laurier University

MENTORISHIP IS A KEY COMPONENT OF MEDICAL EDUCATION, BUT WHAT ABOUT THE YEARS PRIOR TO MEDICAL SCHOOL? IN 2010, MEDICAL STUDENTS CAME TOGETHER WITH MEMBERS OF THE ONTARIO MEDICAL STUDENT ASSOCIATION (OMSA) TO CREATE “ALTITUDE: HEALTHCARE MENTORING,” A UNIQUE INITIATIVE AIMED AT ENCOURAGING AND GUIDING UNDERGRADUATE UNIVERSITY STUDENTS WHO WANT TO PURSUE A CAREER IN HEALTH CARE. The premise of the program is simple: to link first-year undergraduates from rural communities, lower socio-economic backgrounds, and other under-represented communities, with medical students to provide guidance and mentorship during their initial year of university. With approximately 50 participants at three universities when it was first launched in 2010, Altitude: Healthcare Mentoring now boasts more than 350 students at 10 universities across Ontario. Four years on, participants reflect on how important the program has been in helping them to pursue their personal and career goals. Three participants share their experiences, and the benefits of being a mentor or a mentee. Mentee: Josh Kandiah I was paired with Alexander Whelan, a second-year medical student, who was able to offer useful information on what it takes to pursue a career in health care. Our meetings initially consisted of oneon-one talks that focused on the admissions process and medical school curricula. As we got to know each other, our conversations became more casual, and we started discussing my interests and how I could explore them in an effort to get involved in my community and improve my curriculum vitae. Aside from these conversations, Alexander also held a workshop where he helped me practise suturing tech-

niques. I found this experience very practical and motivating, and I am sure it will be helpful in the future. The experiences from this program that I found most beneficial were the various conferences and guest lectures we attended, such as the 2014 BrainTalks Conference on traumatic brain injuries. These talks explored medical topics from multiple perspectives, including health care providers, patients, and affected relatives. Alexander was able to help me understand that empathy is a large component of any health care profession, and knowing this has given me a greater appreciation for the medical profession. The Altitude: Healthcare Mentoring program helped me become more confident about my current program of study, and more certain about the career in health care that I want to pursue. Mentor: Alexander Whelan I am thankful that I had an opportunity to work with Josh and help guide him toward a career in medicine. Together, we approached the year with two main goals in mind. First, I wanted to connect Josh with medical school colleagues from Ottawa and abroad to ensure that he had a comprehensive overview of the medical school application process. Although the Altitude: Healthcare Mentoring program is largely based on oneon-one mentoring, we planned group events that gave Josh and other men8

tees the chance to learn from different medical students. The second goal was to expose Josh to the culture of medicine at the University of Ottawa. We attended lectures and conferences given by patients, doctors and researchers on numerous topics, including dementia care, residential school experiences, and traumatic brain injury rehabilitation. I wanted Josh to use these exposures to reflect on medicine, and to understand the realities of our medical system, the qualities of a good physician, and the reasons for pursuing a career in health care. My intent was to foster his interest in medicine as a way to keep him motivated during the grind of undergraduate studies, and more importantly, to prepare him for the future. Hopefully, there is something that future mentor-mentee pairs can take away from our experience. As I have progressed through two years of medicine, I have realized that mentorship is an important tradition in our profession. I have relied on the advice of physicians and upper-year students to help guide my development, while using their input to make choices regarding electives and research involvement. I also recognize that as I progress through medicine, I will be counted on to develop the competencies of others. Thanks to the program, I have been given the opportunity to hone these skills, and to give back for the mentorship I have received. Vol. 9, Issue 3 – September 2014

Mentor/Mentee: Brooke Raycraft While I was growing up in a small town north of Toronto, I aspired to go into medicine. However, being in a rural community, I found there was very little information or guidance for students interested in a career in health care. When I began my first year at Wilfred Laurier University, I was fortunate enough to hear about the Altitude: Healthcare Mentoring program, and I applied. As there is no medical school at Laurier, I was paired with a medical student mentor from McMaster University — the closest medical school. My mentor not only helped me on my path to a career in health care, but also helped guide me through that daunting first year. The relationship, advice and guidance I received from my mentor, and the teaching sessions throughout the program were invaluable. As a result, I wanted to pass these benefits on to other students, and became a mentor in Altitude’s annual “Basecamp” conference — a weekend event designed to provide students entering their first year of university with the necessary tools to succeed in post-secondary education. As a mentor, and later as part of the Basecamp planning committee, I was able to help students who were in the same situation as I once was. This experience kept me motivated toward my career goals, and I now have successfully finished my undergraduate degree and am beginning my M.Sc. involving the development of drug delivery systems. I owe a great deal to Altitude: Healthcare Mentoring for its enormous influence on my journey, and the impact it has had on my professional and personal growth. Looking forward Altitude is growing on a yearly basis, in large part because of the dedication of its members. The medical student mentors have contributed countless hours to create a program that has benefited more than 1,000 undergraduate students. We feel that we have just scratched the surface of what the program can do and are always looking for more medical student mentors to join the program. To learn more about Altitude: Healthcare Mentoring, please visit http://altitudementoring.ca, and like us on Facebook (facebook.com/ altitudementoring).

Brooke Raycraft (centre left in yellow shirt) practising a cheer with mentees from across the province for Altitude’s 2011 Basecamp conference, held at Ryerson University.

Mentee Josh Kandiah (left) and mentor Alexander Whelan met regularly during their time with the Altitude: Healthcare Mentoring Program. 9

Vol. 9, Issue 3 – September 2014

Words of Advice FEATURE

Before you embark on your social media journey, keep these tips in mind:

Social media and personal branding: should you get an early start in medical school? By Raman Singh, OMA Public Affairs Department

The term “personal brand” may sound like a buzzword, or a concept associated with marketing and communications professionals, but personal branding has an important place in medicine. The rapid increase in the number of physicians turning to social media is indicative of a larger trend in the way health care professionals engage with the Internet.

tribute to online conversations with other medical providers, health care organizations, policy-makers, government officials, and most importantly, the public. Social media affords you the ability to transcend geographic boundaries and have discussions with medical students and doctors around the world, giving you insights from a variety of online influencers. Most government organizations, hospitals, associations and news outlets maintain social media profiles. Social media can help you stay up-to-date on news, political action and policy changes, as well as present the opportunity to offer your own opinions on current events. By doing this, you can foster personal relevance, cultivate knowledge beyond the classroom or medical practice, and keep up with the latest research. If you’re interested in establishing a social media presence, don’t just listen to conversations, but engage in two-way conversations. Think as if you’re continuing a friendly classroom debate in the online sphere — just with a larger audience, and potentially more learning opportunities.

2. Everything happens online Social media is an umbrella term that encompasses the creation and exchange of user-generated content, such as photos, videos, text and audio using webbased and mobile technologies known as Web 2.0. 1 A personal brand can be defined as who you are and what you want to be known for, and is the practice of marketing yourself and your career as a cohesive entity.2 How you present yourself online can have a profound impact on how you are perceived by potential colleagues, employers, and the public before any con-

tact is made. And the most accessible tool to create a positive online identity is social media. We have recently seen an upsurge in the number of Ontario doctors using social media to disseminate health advice, promote their practices, discuss current research and highlight important issues in health care — all while positioning themselves as leaders in their respective areas of expertise. Through platforms such as LinkedIn, Twitter and the blogosphere, numerous opportunities exist for you to leverage social media to create a competi10

formed comments. Social media is instant, and anything you post can be seen by anyone. 5. Choose a platform that best suits you: Twitter and LinkedIn are best used for professional purposes, while Facebook is mainly used for personal social networking. 6. Make connections: Follow organizations and individuals of interest to you. 7. Have fun: Use the opportunity to engage with others in professional conversations and friendly debate about the issues and topics that matter most to you. Don’t be afraid to ask questions and spark conversations.

1. Material published on the Internet is public: If confidentiality is desired, refrain from posting. 2. Exercise caution: Never identify a patient in any way, and refrain from discussing details about individual cases. 3. Follow guidelines: When in doubt, refer to your medical school’s social media policy, or to the Canadian Medical Association’s Social Media Guidelines for Physicians and/or the Canadian Federation of Medical Student’s Guide to Medical Professionalism. 4. Think twice, post once: Be mindful of the information you post online and refrain from posting derogatory or misin-

tive edge for yourself while still in medical school. Below are three important reasons why social media can aid you in your career as a medical professional.

1. Staying up-to-date Approximately 100,000 tweets are generated per minute by Twitter users.3 These tweets are geared towards thousands of topics and conversations, including health care and medicine. While it may seem odd for medical students and doctors to communicate with others through social media, it gives you the opportunity to conVol. 9, Issue 3 – September 2014

We live in a digital world, and when it comes to medicine, it has been said that “social media technologies can augment traditional medical humanities education efforts and perhaps even improve them, as well as prepare students for a future in which social media will play a significant role in medicine.”4 An increasing number of medical schools in the United States have integrated social media into their curricula in order to enhance learning opportunities. Medical students at Penn State College of Medicine enrolled in the course, The Narratives Aging: Explor-

ing Creative Approaches to Dementia Care, found themselves regularly using platforms such as YouTube to provide cross-cultural perspectives on aging and mental health. They also used Twitter for real-time communication between fellow students and their course instructor while conducting storytelling sessions at an assisted-living facility. Twitter allowed the instructor to track student observations and respond to questions in realtime. It also created an archive of insights that were later reviewed during classroom discussion. This has allowed for deeper engagement with course materials and frequent two-way communication between instructors and peers. With this in mind, why not start this year of medical school with the goal of creating a deeper digital presence for yourself? Follow and participate in Twitter chats, such as #HCSMCA (Health Care Social Media Canada) — a community of tweeters exploring medical social innovation by sharing ideas and engaging in friendly debate about the latest health care news in Canada. By participating in the online conversation, you can establish yourself as a thought leader and acquire the tools and skill sets for networking, collaboration and problem solving.

this content can counterbalance reviews and opinions, and contribute credible medical advice. It is an effective form of reputation management, and according to DeCamp, Koenig, and Chisolm, “medical training is a critical developmental period when social media can positively shape professional identity and vice versa.”5 Adopting social media and deciding what you want your digital footprint to convey early in your career can be very beneficial for personal and professional growth. It gives you the time to iron out any inconsistencies and merge your professional and personal identities into a unique personal brand. References: 1. Kaplan AM, Haenlein M. Users of the world, unite! The challenges and opportunities of social media. Bus Horiz. 2010 Jan-Feb;53(1): 59-68. 2. Lair DJ, Sullivan K, Cheney G. Marketization and the recasting of the professional self: the rhetoric and ethics of personal branding. Manage Commun Q. 2005 Feb;18(3):307-343. 3. International Association of Chiefs of Police. Center for Social Media. Fun facts.[Internet]. Alexandria, VA: International Association of Chiefs of Police; n.d. [about 5 screens]. Available at: http://www.iacpsocialmedia.org/Resources/ FunFacts.aspx. Accessed: 2013 Jun 13. 4. George DR, Dellasega C. Use of social media

3. Creating a positive online identity

in graduate-level medical humanities educa-

When doctors type their name into a Google search, chances are physicianranking websites such as RateMDs lead the search results. The content of these websites and reviews do not always accurately reflect a physician’s medical competence. A strong web presence on your part can provide patients and the public with professional online content that is controlled by you. The presence of

tion: two pilot studies from Penn State College

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of Medicine. Med Teach. 2011;33(8):e429-34. Available at: http://informahealthcare.com/ doi/abs/10.3109/0142159X.2011.586749. Accessed: 2013 Jun 13. 5. DeCamp M, Koenig TW, Chisolm MS. Social media and physicians’ online identity crisis. JAMA. 2013 Aug 14;310(6):581-2. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3954788/. Accessed: 2013 Jun 13. Vol. 9, Issue 3 – September 2014

Feature

Twitter’s usefulness for medical students: the role of one social media platform in medical education By Andrew Micieli and Brittany Harrison, University of Ottawa, Med Class 2016, and Dr. Alireza Jalali, Distinguished Teacher and Teaching Chair, Faculty of Medicine, University of Ottawa

Ontarios Doctors @ontariosdoctors • 19m Since its creation in 2006, Twitter’s popularity has rapidly grown. With more than 255 million users sending in excess of 500 million tweets daily, it is one of the top-10 most frequently visited websites on the Internet.1 Among medical students, Twitter is currently an underutilized tool. There are many uses for such a platform within the medical community, including acting as a network where medical students, patients, residents, physicians, and other health care providers can communicate with one another. And yes, we realize this intro is longer than Twitter’s allotted 140 characters. Expand

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addition to communication and healthy debate among both medical students and other health care professionals. During health care conferences, live tweeting has become a useful way for medical students to connect with the medical community through the sharing of medical knowledge and health care innovations in real time.6 Conference-specific hashtags have been created for these events that allow attendees and Twitter users to stay up-to-date on the conference through live tweeting, while also engaging in a dialogue about its content. For example, the Canadian Medical Association 2013 General Council in Calgary used the hashtag #CMAgc to promote the conference discussion on pertinent issues facing the Canadian health care system. During the week-long conference, more than 2,860 tweets were sent

using the hashtag #CMAgc.7 For a comprehensive list of health care conferences and their associated hashtags from 2011 through to 2015, visit http://www.symplur. com/healthcare-hashtags/conferences/all. One way to quantify Twitter’s growing influence on medical education and the medical community is to track the #MedEd hashtag. Using the health care social media analytics database Symplur, it is possible to track this hashtag over a one-year period. From November 1, 2011 to November 1, 2012, a total of 62,462 tweets were sent using the hashtag #MedEd, with a total of 8,197 participants. These numbers grew to 133,963 tweets sent, with a total of 18,110 participants the following year. The above statistics demonstrate the two-fold increase in medical education tweets from one year to the next, and this trend is expected to continue in the future.

User Name

Its potential in medicine was identified early on by Phil Baumann, who in 2009 created a list of 140 potential uses for Twitter in health care.2 This list includes supportive care for patients and family members, daily health tips from authoritative sources, physician opinion-sharing, medical education, publishing healthrelated news, fundraising for hospitals and health-related causes, and livetweeting at medical conferences. In recent years, Twitter’s potential has begun to be exploited, as an increasing number of physicians are using it in their daily communications. Its use by certain special interest groups to gather public opinion and introduce targeted campaigns has also been identified.3 In addition, medical schools, journals, hospitals, and biotech organizations, among other entities, are also tweeting daily to interact with the public and stakeholders, as well as to enhance professional collegiality and scientific research. According to a 2013 edition of Journal Citation Reports, nine of the top-10 general medical journals have a dedicated Twitter feed that promotes new articles and features in their publications. This alone has the potential to help medical students increase their awareness of important health topics that will be useful in both their studies and future careers.

Twitter as an educational tool for medical students Twitter’s main advantage for medical students is that it provides a convenient platform for staying abreast of current medical events and daily news. Rather

than bouncing between numerous websites, Twitter provides a constantly updated amalgamated stream of relevant articles to explore. One aspect of Twitter that easily facilitates the sharing of information is known as a hashtag, which is a word or phrase preceded by a pound sign (#). Hashtags are used to identify messages on a specific topic. With millions of tweets being posted at any given time, sifting through them can be difficult. Hashtags help solve this problem by making it easy to search for tweets with specific hashtags that are of interest to students. 12

The use of hashtags makes Twitter a useful study tool and support network for medical students.4,5 Students can tweet questions to each other using hashtags that allow their questions to be easily searched and accessed. Students can offer support, study tips, and encouragement to each other through reflection and the sharing of memorable learning experiences. These questions are available not only to students, but also to other health care professionals who can provide answers. Twitter can become a tool for engaging in active learning, a forum for debate and patient advocacy, a resource to reinforce classroom knowledge, and a means for promoting collaboration among medical students across the world. It can be difficult for students who are new to Twitter to identify medical-related feeds worth following. We’ve listed our top Twitter feeds in the table on page 9. These feeds provide an excellent starting point for you to build, or update, your Twitter profile. Co-author Andrew Micieli created and operates a Twitter feed specifically tailored for medical students called MedStudentBlog (@medstudent_blog) — an interactive feed that highlights interesting news stories that directly affect medical students. By using the hashtag #MedEd (for medical education) in tweets, the blog is able to facilitate easy access to an aggregate of medical education news, in Vol. 9, Issue 3 – September 2014

Limitations of Twitter and future use Like other social media outlets, there are limitations to using Twitter. For first-time users, Twitter can feel overwhelming and has the potential for unprofessional behaviour when not used appropriately. Many students do not see social media as part of their professional identity, and it can be difficult to differentiate between public and private content. This can give way to lapses in professionalism.8,9 The permanence and worldwide reach of online posting is important to keep in mind. There are inherent risks in placing any content online, as online misdemeanours can affect one’s future employment, and can compromise the public’s perception of the medical field.10,11

About

Top study tool Twitter feeds

(continued on page 15) Tweets*

Followers*

* as of July 31, 2014

USMLE (@master_usmle)

United States Medical Licensing Exam

17,700

58,300

Radiopaedia.org (@radiopaedia)

Collaborative radiology resource

3,143

7,725

Figure 1 (@figure1)

Photo sharing app

553

924

Top medical news Twitter feeds André Picard (@picardonhealth)

Public health reporter

31,600

25,700

NYTimes Health (@nytimeshealth)

New York Times health news

20,600

644,000

OMA (@OntariosDoctors)

Ontario Medical Association

5,839

13,200

healthydebate.ca (@HealthyDebate)

Debate about health policy issues

3,806

5,186

ICES (@ICESOntario)

Institute for Clinical Evaluative Sciences

1,976

3,861

868

2,864

Top medical student Twitter feeds MedStudentsBlog (@medstudent_blog)

News affecting medical students

Cdn Medical Students (@CFMSFEMC)

Canadian Federation of Medical Students

1,279

2,921

Medscape Med Student (@MedscapeStudent)

Medscape Medical Students

8,801

18,600

Dr. Kevin Pho (@kevinmd)

Physician, author, keynote speaker

27,400

107,000

Dr. Brian Goldman (@NightShiftMD)

Emergency room physician, author, and host of CBC’s White Coat, Black Art

15,300

118,000

Dr. Atul Gawande (@Atul_Gawande)

Physician, writer, researcher

2,083

94,200

CMAJ (@CMAJ_News)

Canadian Medical Association Journal

3,582

11,000

JAMA (@JAMA_current)

Journal of the American Medical Association

6,916

84,900

BMJ (@BMJ_latest)

British Medical Journal

15,800

133,000

Top physician Twitter feeds

Top journal Twitter feeds

Top medical education Twitter feeds MedEd Chat (@MedEdChat)

Medical education chat

3,258

2,430

Dr. Jason Frank (@drjfrank)

Clinician educator, emergency medicine physician

17,100

2,597

The Royal College (@Royal_College)

The Royal College of Physicians and Surgeons of Canada

3,561

3,678

13

Vol. 9, Issue 3 – September 2014

Feature

the medical humanities and it is our hope that both students and their patients will reap the benefits of this effort.

edu/. Accessed: 2014 Jun 12.

4. Charon R. What to do with stories: the sci-

2. Banaszek A. Medical humanities courses

ences of narrative medicine. Can Fam Physician.

becoming prerequisites in many medical schools.

2007 Aug;53(8):1265-7. Available at: http://

CMAJ. 2011 May 17;183(8):E441-2. Available at:

www.cfp.ca/content/53/8/1265.full. Accessed:

http://www.cmaj.ca/content/183/8/E441.long.

2014 Jun 12.

exploring medical humanities at Queen’s University

References

Accessed: 2014 Jun 12.

5. Watson S. An extraordinary moment: the heal-

1. Aull F. Medical humanities: mission statement.

3. Murray TJ. Why the medical humanities.

ing power of stories. Can Fam Physician. 2007

By Hollis Roth, Queen’s University, Med Class 2016

[Internet]. New York NY: School of Medicine,

[Internet]. Halifax, NS: Faculty of Medicine,

Aug;53(8):1283-7. Available at: http://www.cfp.

New York University; c1993-2014. [about 1

Dalhousie University; c2004-2011. [about 10

ca/content/53/8/1283.long. Accessed: 2014

screen]. Available at: http://medhum.med.nyu.

screens]. Accessed: 2014 Jun 12.

Jun 12.

(continued from page 13)

come familiar with Twitter before starting to tweet; 2) to remember that what you post online is your digital footprint and can be traced back to you, and; 3) to create subscription lists to keep social and educational home feeds separate. While the use of Twitter is expanding in the field of medicine, currently it is a tool that is underutilized by medical students. Twitter has the potential to be a very useful resource for students, and it is our hope that this article helps to outline some of its many educational benefits, provide a list of recommended feeds to customize your account, and offer useful tips for overcoming some of the barriers to using this valuable tool.

ences: educational or just another distraction?

Medicine and Literature:

Every second Thursday from September to May, a small group of medical students gathers at the Ban Righ Centre on the Queen’s University campus. At first glance, this collection of students can seem a familiar scene. However, instead of heavy textbooks, pieces by Alice Munro, Anton Chekhov, and Atul Gawande litter the floor, and the air is filled with animated discussion of prose and poetry. “Medicine and Literature” is in session. The Medicine and Literature program at Queen’s was conceived in the 1960s by Dr. Jacalyn Duffin and professor Mark Weisberg as a collaboration between the university’s medical and legal faculties. Originally entitled “Images of Doctors and Lawyers,” the program included 12 students from each faculty who attended the course on a weekly basis — law students received credit for the course, while medical students took the course as an elective — and the assigned readings drew from both professions. Following Weisberg’s retirement in 2010, the legal faculty stopped offering the course, and its present form as Medicine and Literature was born. Currently the course is offered as a full-year elective to medical students and is facilitated by Dr. Sadiqa Khan, a published poet (as Sadiqa de Meijer), and Dr. Shayna Watson. Assigned readings strive to cover topics including health, illness experiences, and the patient-physician relationship through selected works of poetry, short fiction, essays, and novels related to medicine. The medical humanities — spanning the humanities, social sciences, and arts, with a focus on human values and the applications of these areas to medical education and clinical practice — have increasingly been acknowledged as an important area of medical education. 1,2,3 In contrast to medical schools in the United States, where structured

and well-defined medical humanities curricula are often in place, Canadian medical schools tend to offer medical humanities courses on an elective basis.2 Within the context of the emerging focus on the importance of the humanities in medicine, forums such as Medicine and Literature allow students to explore a variety of issues surrounding medicine. The benefits to medical students in strengthening their knowledge base in the medical humanities are not solely restricted to personal growth. Narrative medicine explores the idea of narrative competence: that by having the ability to appropriately connect with and emotionally respond to a patient, students can establish a deeper connection and offer improved treatment and care.4 While current curricula teach medical students to think of disease courses in an aseptic and linear fashion, patient narratives rarely arrive neatly packaged and ready for dissemination. 5 By enhancing their ability to see the entirety of each patient’s story, medical students can improve their capacity to deliver truly patient-centred care. In the past year, Medicine and Literature has covered topics ranging from end of life care (Atul Gawande’s Letting Go: What Should Medicine Do When It Can’t Save Your Life), errors in medicine (Mistakes by David Hilfiker), and rural medicine in the 1940s (Eugene Smith’s photo 14

essay, A Country Doctor), along with several other selected works of poetry, short stories, essays and art that at first glance may seem only loosely related to medicine. Upon deeper reflection, these texts contain a wealth of avenues to explore. By cultivating an atmosphere that encourages reflection and discussion in a group setting, Medicine and Literature enables students to connect themes and motifs explored in selected pieces to experiences in their training. Drawing from students across all four years of medical training further strengthens the impact of the readings, as students are able to share different perspectives and reflect on their own experiences. The program continues to evolve. Creative writing workshops are regularly held, and the first student anthology — a collection of students’ poetry, prose, and graphic art, entitled Mixed Gears: Writing and Art by Medicine and Literature Students was published this year. The anthology’s enthusiastic reception is telling of the increasing awareness and importance of the medical humanities at Queen’s University. Dr. Watson precisely captures the synergistic relationship between the sciences and humanities when she states that, “evidence-based medicine helps us understand populations, while narrative helps us understand individuals.”5 Medicine and Literature continues to strive to enhance student exploration of Vol. 9, Issue 3 – September 2014

Twitter’s usefulness for medical students A 2013 survey demonstrated that an increasing number of surgical residency program directors look at an applicant’s social networking profiles. The applicant is often judged differently once their social media site has been viewed, and one-third ranked an applicant lower after investigating their online presence.12 It is important for medical students to remember that online activity holds many benefits for promoting accomplishments and past activities, but may also have negative implications for their future careers if their online activity is unprofessional.” In 2013, the Canadian Federation of Medical Students (CFMS) published guidelines on social media professionalism, which state that medical students, as proto-professionals, should act in a way that they would feel comfortable observing their own physicians acting away from clinical duties. 13 This document provides information on how medical students should conduct themselves in the public eye, as well as guidelines regarding professional boundaries online. The CFMS guidelines are currently being used at a number of Canadian medical schools to provide concrete guidance to medical students. An online guide is also being developed at the University of Ottawa by Andrew Micieli as part of the medical school curriculum. Designed to help educate medical students on the use of Twitter as an educational tool, the guide also provides information, instruction and guidelines on online professional behaviour that build on those created by the CFMS. Three general recommendations for students using Twitter are: 1) to be-

Med Educ. 2013 Nov;47(11):1129-30. Available from: http://onlinelibrary.wiley.com/doi/10.1111/ medu.12337/pdf. Accessed: 2014 Mar 14. 7. Canadian Medical Association. #CMAgc conference hashtag: CMA general council 2013. 2013 Aug 21. Tweets [Twitter page]. Available at: http://www.symplur.com/healthcare-hashtags/ cmagc/. Accessed: 2014 Jun 11. 8. Kaczmarczyk JM, Chuang A, Dugoff L, Abbott JF, Cullimore AJ, Dalrymple J, Davis KR, Hueppchen NA, Katz NT, Nuthalapaty FS, Pradhan A, Wolf A, Casey PM. e-Professionalism: a new frontier in medical education. Teach Learn Med. 2013;25(2):165-70. Available from: http:// www.tandfonline.com/doi/pdf/10.1080/1040133 4.2013.770741. Accessed: 2014 Mar 14. 9. DeCamp M, Koenig TW, Chisolm MS. Social media and physicians’ online iden-

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1. Forgie SE, Duff JP, Ross S. Twelve tips for

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using Twitter as a learning tool in medical educa-

data/Journals/JAMA/927436/jvp130093.pdf.

tion. Med Teach. 2013;35(1):8-14.

Accessed: 2014 Mar 14.

2. Baumann P. 140 health care uses for

10. Chretien KC, Greysen SR, Chretien JP, Kind T.

Twitter. Phil Baumann: Better Living Through

Online posting of unprofessional content by medi-

Enquiry. [blog on the Internet]. 2009 Jan

cal students. JAMA. 2009 Sep 23;302(12):1309-

16. [place unknown]: Phil Baumann. c2014.

15. Available from: http://jama.jamanetwork.com/

[about 10 screens]. Available from: http://phil

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baumann.com/140-health-care-uses-for-twitter.

pdf. Accessed: 2014 Mar 14.

Accessed: 2014 Mar 14.

11. Belean GD, Truong J. Social media and

3. Micieli R, Micieli JA. Twitter as a tool for

medical students. Medical Student Journal of

ophthalmologists. Can J Ophthalmol. 2012

Australia, 2011 Jun;3(1):21–3. Available from:

Oct;47(5):410-3.

https://eview.anu.edu.au/medical_journal/

4. Cheston CC, Flickinger TE, Chisolm MS.

vol3_11/pdf/ch05.pdf. Accessed: 2014 Mar 14.

Social media use in medical education: a system-

12. Go PH, Klaassen Z, Chamberlain RS. Attitudes

atic review. Acad Med. 2013 Jun;88(6):893-901.

and practices of surgery residency program direc-

5. Chan B. #TwitterStudying: A med stu-

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dent’s experiences with Twitter as a study tool

select residency candidates: a nationwide survey

and support network. 2011 Jun 24. In: Kim

analysis. J Surg Educ. 2012May-Jun;69(3):292-300.

J. Medicine and Technology.com. [blog on the

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6. Jalali A, Wood TJ. Tweeting during confer-

Accessed: 2014 Mar 14.

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Vol. 9, Issue 3 – September 2014

FEATURE

which are key to both arts and health care. My clinical skills class regularly reinforced that inspection is very important in physical exams, as the ability to “paint a picture” of the patient by picking up telling details is a hallmark of an astute clinician. Yet, observational skills are rarely taught formally in the curriculum.1 One exception is when Weill Cornell Medical College and The Frick Collection (an art museum in New York) collaborated on a pilot project to introduce a medical education program where students examined painted museum portraits and then applied the observation and interpretation skills to photographs of patients’

Arts-based learning: how visual arts can improve medical education By Victoria YY Xu, Queen’s University, Med Class 2016

faces.2 A study of the program found improved observational skills among the students, as well as increased awareness of expressions in the human face.2 By actively participating in arts-based learning over the course of the internship, I was put in the frame of mind to pay more attention to the visual cues around me. Beyond observational skills, this arts-based learning experience also encouraged me to reflect on my own experiences. Comparing the process of reflecting through artwork versus writing has taught me that visual images are not only capable of complementing words, but more importantly, they can

trigger deeper emotions and feelings. By relying on observations and reflections rather than following a step-by-step, planned-out approach, I ended up creating a more organic product, one that I had never envisioned in blueprint form at the outset. References 1. Dolev JC, Friedlaender LK, Braverman IM. Use of fine art to enhance visual diagnostic skills. JAMA. 2001 Sep 5;286(9):1020-1. 2. Bardes CL, Gillers D, Herman AE. Learning to look: developing clinical observational skills at an art museum. Med Educ. 2001 Dec;35(12):1157-6

I was not expecting to pick up a paintbrush, let alone come home with ink-smudged hands when i started as an intern at the baycrest centre for learning, research and innovation. it turned out that, in addition to the speaker series, clinical experiences and various inter-professional activities, the internship program

A

B

C

D

included a unique arts-based learning project.

In the first session, I was given an accordion book with 12 blank pages, along with two printmaking blocks, and was told that we would be carving prints to reflect themes that illustrate our internship experiences. Faced with such an abstract and undefined task on both the visual and conceptual levels, my efforts to come up with a theme during allocated studio time were largely fruitless. Instead, inspiration came to me while I was strolling through the halls; my mind was less fixated on the task and more receptive and attentive to my surroundings. The two prints that I finally decided to create were inspired by powerful imagery that I noticed in my environment:

a painting of an eye at the entrance to one of the long-term care sections, and a statue of a mother and child outside the entrance to Baycrest. In order to come up with meaningful themes, I had to gather “data” from my environment — both internal (my thoughts and feelings) and external (internship activities and interactions with others). To further stimulate my ideas, I drew from the reflections that we wrote at the end of each week. I wanted to visually incorporate those memorable moments, such as witnessing older adults learning pottery for the first time at the day centre, and the eye-opening experience of shadowing a personal support 16

worker. I felt it was not enough to just look — I challenged myself to “see” — to process visual clues, to think and reflect upon them, and to make connections. After gathering enough “data,” I was able to identify key themes to highlight in my art book: the power of eye contact and perspectives in communication (see image A on page 17), inter-generational connections (image B), creativity and community engagement for the elderly (image C), and nurturing caregiverpatient relationships (image D). Through this arts-based learning experience, I realized the potential for visual arts programs in medical education as a means to cultivate observational skills, Vol. 9, Issue 3 – September 2014

Victoria YY Xu of Queen’s University found herself creating artwork as part of her internship at the Baycrest Centre for Learning, Research and Innovation. Above is some of her work: A: eye contact and perspectives in communication, B: inter-generational connections, C: creativity and community engagement for the elderly, D: nurturing care-giver-patient relationships.

17

Vol. 9, Issue 3 – September 2014

FEATURE

An overview of the different methods used in clerkship teaching By Natasha Larocque, University of Ottawa, Med Class 2015

Despite the early mornings, a sporadic sleep schedule, and READINGS THAT SEEM TO NEVER END, CLERKSHIP PROVIDES AN OPPORTUNITY FOR Medical students TO EVOLVE CLINICAL skills and KNOWLEDGE IN A RELATIVELY SHORT TIME. THE TEACHING MODALITIES used by preceptors are crucial to this process, and it’s important to understand how, and why, they are used. Looking back on my clerkship experience, I realize how much my comfort level with establishing differential diagnosis, determining the appropriate work-up for a presenting complaint, and developing a good patient rapport has grown. The advancement of these competencies has been greatly influenced by the physicians I have worked with, and the different teaching strategies they’ve utilized to assess and develop my clinical skills. Below is an overview of the teaching techniques that I’ve been exposed to, my experience with them, and literary evidence on each technique’s effectiveness. Pimping In my experience, the most commonly used teaching technique is pimping, which has been defined as the clinical practice where people in power ask questions of their junior colleagues. 1 Although many medical students, myself included, have expressed fear and discomfort around the use of pimping, many admit to its effectiveness. It can be distressing to be put on the spot, to be the centre of attention while you are attempting to come up with an answer, or to state an incorrect answer in the presence of others. However, this technique brings to light areas of weakness that require further attention. I find that I am better able to remember answers to questions that I have answered incorrectly, and I have a greater motivation to read about a particular subject if I had trouble during a pimping session. According to a survey of fourth-year

medical students, other benefits of pimping include an increase in logical thinking, a refined ability to defend a decision, and a better aptitude for self-assessment.2 That being said, pimping also has drawbacks. In an article on the art of pimping, published in the Journal of the American Medical Association, examples of topics that have little teaching utility were offered, including arcane points of history, teleology and metaphysics, exceedingly broad questions, eponyms, and technical points of laboratory research. 3 Pimping that is conducted to humiliate or to demonstrate how little a student knows on a particular topic is also considered detrimental to learning.2 These findings further suggest that the technique should be non-competitive and avoid drilling students unnecessarily.2 A positive learning environment is required for the efficacy of pimping; it serves to decrease the student’s anxiety, and promote confidence in answering questions. Ultimately, I’ve found that pimping can be an invaluable teaching strategy when well executed. Presentations For most rotations, students are expected to give a presentation on a specific topic in front of their peers. I find this form of self-directed learning to be quite beneficial. Giving a presentation forces the student to become an expert in a particular area. For example, I gave a presentation on hypertension during my family medicine rotation, and I’m consequently very comfortable with this material. Stu18

dents utilize critical thinking and research skills as they must evaluate an inordinate amount of information and determine the key points that should be included in the presentation. Students also enhance their communication skills by delivering an oral presentation to their peers at an appropriate pace and rhythm. Early in medical education, students are exposed to the CanMEDS framework, which is a guide to the essential abilities physicians need for optimal patient outcomes.4 In my opinion, creating and delivering a successful presentation helps refine several CanMEDS roles, including communicator, collaborator (for group presentations), and scholar. As future physicians, it is important to master and hone these specific competencies in order to provide optimal patient care. I believe giving peer presentations during clerkship is a great teaching tool used by staff to work on these skills. Assigned readings Some preceptors give their clerks readings as homework. This technique may seem elementary, but I find it helps direct studying, and gives a focus for evening readings. Preceptors may give readings so that you are better prepared for a planned pimping session, while others suggest readings to solidify a case that was seen that day. For example, while interpreting an electrocardiogram (ECG) during my cardiology rotation, I had determined that there was no left ventricular hypertrophy (LVH) as the Sokolow-Lyon voltage criteria had not been met. HowVol. 9, Issue 3 – September 2014

ever, using other established criteria, it was found that there was, in fact, LVH. My preceptor subsequently encouraged me to read on the different criteria that can be used to determine LVH on ECG and to present them to him the following day. Interestingly, a 2009 study demonstrated that there was no difference in overall clinical performance in medical students who were given mandatory readings, compared to students who did not have any required readings. 5 Another study showed that clerks reported reading an average of 10.8 hours per week. 6 The most commonly used resources were UpToDate.com and test preparation books, although 39% of students found that they had insufficient time to read, 12% did not know the best resource available to read about patients, and 11% did not know what to focus on while reading.6 Consequently, while assigned readings may not have demonstrated efficacy in terms of clinical performance, I believe suggestions for readings by staff may help alleviate student stress by focusing their studying on important concepts, and by offering level-appropriate resources. Observation Perhaps the most intimidating of all the teaching strategies is a preceptor observing a student’s clinical encounter with a patient. No matter how many times my preceptor tells me to pretend as if they are not in the room, I cannot get the idea out of my head that someone is judging my every move. Nevertheless, I have truly learned a lot from this technique because preceptors are able to give very specific feedback on my performance. For instance, while I was in psychiatry, my preceptor observed an entire clinical encounter between myself and a new patient. Afterwards, he explained how to better structure my history, and offered tips on how to better probe for the presence of delusions. Systematic reviews identified observation tools that could be used to assess medical trainees’ skills in a clinical encounter.7 Of the 55 observational tools identified, the Mini Clinical Evaluation Exercise (also named Mini-CEX) had the strongest validity. 7 The University of Ottawa utilizes the Mini-CEX as a tool to evaluate student performance and competence in various clinical rota-

tions. Although I typically leave these evaluations to the end of my rotation, since it is when I feel more comfortable with my histories and exams, in the future, I will try to utilize this tool earlier on, for the feedback I receive positively impacts my clinical skills. See one, do one, teach one The infamous maxim of “see one, do one, teach one” in medical education encourages students to engage in experiential learning after having observed a particular skill, and then solidify their knowledge by teaching their peers. I believe this technique is vital to our education. It is important for clerks to obtain hands-on experience and to practise their clinical skills. However, on more than one occasion, I was expected to perform a task without having observed it first. For instance, during my first day in obstetrics, I was asked to do a prenatal followup. Although the clinical encounter went well, I felt that my interview was disorganized, and I did not ask a few key clinical questions because I had not seen a prenatal visit done before. Birnbaumer offers suggestions to improve the “see one, do one, teach one” motto, which I find quite insightful.8 To illustrate, for the “see one” component, teachers should break a procedure down in a series of simple steps and talk through the procedure. For the “do one” component, the learner should be asked to verbalize every step of a procedure while performing it. For the “teach one” component, the learner should be observed when teaching others for the first time.8 In an age where patient safety is garnering greater media attention, a key message for medical students is that if you feel uncomfortable about performing a certain task, do not feel shy about bringing concerns forward to your preceptor. I have had a few preceptors who gave me a great deal of independence, but whenever I was in doubt, or wanted a second opinion, I always asked for their help to verify my findings. I believe allowing clerks to try new clinical skills is very important. It allows us to refine our competencies and increase our confidence, but it is important to realize the limitations inherent in “see one, do one, teach one,” and that it is okay, and often necessary, to ask for help. 19

Take-home message A medical student’s preference for the different teaching strategies ultimately depends on his or her learning style. It is important for students to know their strengths regarding their learning strategies in order to make the most of clerkship. If a student is uncomfortable with the pimping technique, they could ask their colleagues to quiz them on certain topics, or if a student needs to see a procedure more than one time before performing it themselves, preparing for clinic using online videos may be useful. In clerkship, students refine the learning skills required for the remainder of their careers, and this process is facilitated by teaching.

References: 1. Le T, Bhushan V, Amin C. First aid for the wards: insider advice for the clinical years. 2nd ed. New York, NY: McGraw-Hill; 2002. 2. Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping: perspectives of 4th year medical students. Teach Learn Med. 2005 Spring;17(2):184-91. 3. Brancati FL. The art of pimping. JAMA. 1989 Jul 7;262(1):89-90. 4. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 framework. Ottawa, ON: Royal College of Physicians and Surgeons of Canada; 2005. [cited 2014 Feb 1]. Available from: http://www.royalcollege.ca/common/documents/canmeds/framework/the_7_canmeds_ roles_e.pdf. Accessed: 2014 Apr 22. 5. Hoffman L, Bott K, Puumala S, Shostrom V. Influence of assigned reading on senior medical student clinical performance. West J Emerg Med. 2009 Feb;10(1):23-9. Available from: http://www. ncbi.nlm.nih.gov/pmc/articles/PMC2672302/ pdf/0100023.pdf. Accessed: 2014 Apr 22. 6. Leff B, Harper GM. The reading habits of medi cine clerks at one medical school: frequency, usefulness, and difficulties. Acad Med. 2006 May;81(5):489-94. 7. Kogan JR, Holmboe ES, Hauer KE. Tools for direct observation and assessment of clinical skills of medical trainees: a systematic review. JAMA. 2009 Sep 23;302(12):1316-26. Available from: http://jama.jamanetwork.com/data/ Journals/JAMA/4481/jrv90008_1316_1326.pdf. Accessed: 2014 Apr 22. 8. Birnbaumer DM. Teaching procedures: improving “see one, do one, teach one.” CJEM. 2011 Nov;13(6):390-4. Available from: http://www.cjemonline.ca/sites/default/files/CJEM_2011_110386. pdf. Accessed: 2014 Apr 22. Vol. 9, Issue 3 – September 2014

Feature

The hidden curriculum:

exploring the unspoken culture of medicine and specialty By Kevin Dueck, Western University, Med Class 2016

BECOMING A PHYSICIAN INVOLVES MORE THAN DEVELOPING SPECIFIC TECHNIQUES, SKILLS AND REASONING THROUGH FORMAL EDUCATION. MEDICAL TRAINING IS ALSO COMMUNICATED THROUGH INFORMAL ACTIONS THAT REFLECT THE VALUES AND CULTURE OF OUR PROFESSION.

1

The hidden curriculum When we started medical school, our class was told about a secondary or “hidden” curriculum2 — one not present in the objective lists, but which nonetheless conveys powerful messages about the underlying principles and beliefs of our profession. As students, it’s important to remember that whenever we enter a lecture hall, clinic, or operating room to further our medical training, we are also absorbing the “hidden” lessons conveyed through the language, gestures, and actions of our instructors, mentors and peers. These lessons will not only inform the way we perceive ourselves and our profession, but will also influence, for better or worse, how we interact with each other, with our patients, and within the medical community. How professional culture is communicated during medical training is a topic that is currently receiving a lot of attention. The recent publication of Dr. Brian Goldman’s The Secret Language of Doctors sparked significant discussion around the language we use in referring to patients, and when dealing with clinical situations and each other. With the importance placed on mentorship during medical training, these messages have ample time to be internalized by students.3 It is also important to note that lan-

guage is only one aspect of the hidden curriculum, and that it extends beyond comments, jokes or labels. It is also found in the structure of our training, how much time is spent on each subject, and how our curriculum is aligned to focus on the needs of the public. The hidden curriculum also encompasses how we learn to interact with patients, as well as the unspoken rules and hierarchy of medicine that are reinforced through example.4 It’s important that the profession takes the time to reflect on its values and be transparent with the public it serves. As part of this process, we must examine the underlying culture in order to find ways to keep what is useful while discarding that which prevents progress or causes conflict. A primary (care) target One aspect of the hidden curriculum that has become apparent is the tension between medical specialties that is made apparent through the use of language. While jokes and comments that disparage or belittle one speciality with respect to another are not uncommon, the negative attitude directed toward family medicine in particular is more sustained, and appears to be deeper. While attending an evening of medical student performances at Queen’s U n i v e r s i t y, D r. To n y S a n f i l i p p o — 20

Queen’s University’s Associate Dean of Undergraduate Education — was disturbed by the messages in the performances that painted family medicine as an undesirable career. So much so, that he interviewed students and began a public dialogue about it.5 With many students entering the field of family medicine, it’s surprising that this negative attitude persists. According to the 2014 Canadian Residency Matching Service statistics, nearly 40% of medical graduates selected family medicine as their top choice, with 94% of positions being filled in the first iteration. Family medicine is an increasingly competitive field, and one that students are aiming for despite it often being portrayed as a fallback option or a career of last resort. Of course, there are differences between those pursuing family medicine and those pursuing other fields. This is not to say that students who pursue family medicine are true to the stereotypes of being less ambitious or driven, but rather they are students with unique preferences and backgrounds, including those in long-term relationships, those from rural communities, those interested in social issues, and female students.6-10 Family medicine is a community-based field requiring generalist skills, and involves ongoing patient relationships. Comments diminishing the field are common, and the hidden curriculum Vol. 9, Issue 3 – September 2014

can often make this explicit. Reminders that certain slides can be ignored or forgotten if a student is planning on becoming a family doctor grind on those passionate about the field. Sometimes comments can be more personal, for example, a student being asked about his or her career plans during an evaluation, and being told, “You have such potential, it would be such a shame if you ended up in family medicine.” Such comments have a lasting impact and can alter a student’s perception of a field and its worth.11 While the basis of the devaluation of family medicine specifically is complex, its causes are often difficult to identify. Dr. Sanfilippo identified four contributing factors: diagnostic uncertainty, technology, remuneration, and prestige.5 To these I add the issues of the perceived value of generalist to specialist practitioners, the lack of exposure to family medicine during training, and the portrayal of physicians in the media. W ith the complexity of moder n medical technology and research, it is easy to see conflict arising between ever more disparate fields of practice. It’s much easier to cast derision on someone you’ve never interacted with, affixing labels and defining stereotypes. The time given to each subject — as well as the length and complexity of their objective lists and methods of assessment — is another aspect of the hidden curriculum. If family medicine is not focused on and given appropriate time in the curriculum, its perceived importance to the medical field is communicated to students through its absence. Similarly, the shorter residency of family medicine may be seen as a value statement, reinforcing a perceived medical hierarchy. Finally, there is a famous photograph of the late heart surgeon Dr. Zbigniew Religa, following a successful 23-hourlong heart transplantation. Dr. Religa, exhausted, squats on a stool beside his still intubated patient, hands speckled with blood. Across the room his assistant, long asleep, is slumped against the wall. Images like this stick with you and can shape your view of a profession. If this is what students and their professors see as “real medicine,” I can appreciate how this would shape their perception of community-based practice. The portrayal of

doctors on television has a similar iconic nature. The physician acting as detective while the patient’s body and history serve as vehicles to drive the plot forward. Here, medicine is being represented as an acute profession with a mystery or puzzle to solve, and always solvable within an hour. These versions of medicine are incongruent with family medicine, which rarely finds representation. We require a realistic appreciation of the contributions made by the diverse range of specialties. Perception by both the profession and the public is influenced by the popularized version of medicine, which in turn contributes to the stereotypes and attitudes around primary care. While the underlying causes of the attitudes toward family medicine and some specialties may be complex, they must be overcome. The messages sent to students not only devalue the work of our peers, but the patients and communities they serve. Fostering cross-professional repect among all medical specialties is possible and worth striving toward — where each specialty is valued for its contributions, and collaboration is pursued to bring about the best outcomes for patients.

action: a social cognitive theory. Englewood Cliffs, N.J.: Prentice Hall; 1986. 3. Bevis EO, Watson J. Toward a caring curriculum : a new pedagogy for nursing. Sudbury, MA: Jones and Bartlett; 2000. 4. Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ. 2004 Oct 2;329(7469):770-3. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC520997/. Accessed: 2014 Jul 3. 5. Sanfilippo A. Family medicine and the hidden curriculum: lessons from medical variety night. [Includes 21 responses]. 2013 Feb 4. In: Queen’s University. Faculty of Health Sciences. School of Medicine. Undergraduate School of Medicine blog. [Internet]. Kingston, ON: School of Medicine, Faculty of Health Sciences, Queen’s University, c2014. [about 12 screens]. Available at: http://meds.queensu.ca/blog/ undergraduate/?p=323. Accessed: 2014 Jul 3. 6. Woloschuk W, Wright B, McLaughlin K. Debiasing the hidden curriculum: academic equality among medical specialties. Can Fam Physician. 2011 Jan;57(1):e26-30. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/ pmid/21252122/. Accessed: 2014 Jul 3. 7. Scott I, Gowans M, Wright B, Brenneis F, Banner S, Boone J. Determinants of choosing a career in family medicine. CMAJ. 2011 Jan 11;183(1):E1-8. Available at: http://www.

Conclusion “They always say time changes things, but you actually have to change them yourself.” — Andy Warhol The hidden curriculum pervades our training and profession, and we must be mindful of it as it reflects our values. An early warning to students is a start, but awareness isn’t enough. There are many disconcerting aspects of our present culture that we must make explicit and address. Changing culture is difficult, but it can and must be done as the hidden curriculum can “undermine us as caring, ethical professionals.”1 The goal needs to be one of cultivating a caring culture of mutual respect that will benefit the profession, and ultimately the public we serve.

ncbi.nlm.nih.gov/pmc/articles/PMC3017271/. Accessed: 2014 Jul 3. 8. Selva Olid A, Zurro AM, Villa JJ, Hijar AM, Tuduri XM, Puime AO, Dalmau GM, Coello PA; Universidad y Medicina de Familia Research Group (UNIMEDFAM). Medical students’ perceptions and attitudes about family practice: a qualitative research synthesis. BMC Med Educ. 2012 Aug 21;12:81. Available at: http://www. ncbi.nlm.nih.gov/pmc/articles/PMC3546071/. Accessed: 2014 Jul 3. 9. Vanasse A, Orzanco MG, Courteau J, Scott S. Attractiveness of family medicine for medical students: influence of research and debt. Can Fam Physician. 2011 Jun;57(6):e216-27. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3114693/. Accessed: 2014 Jul 3. 10. Gill H, McLeod S, Duerksen K, Szafran O. Factors influencing medical students’ choice of family medicine: effects of rural versus

References

urban background. Can Fam Physician. 2012

1. Mahood SC. Medical education: beware the

Nov;58(11):e649-57. Available at: http://www.

hidden curriculum. Can Fam Physician. 2011

ncbi.nlm.nih.gov/pmc/articles/PMC3498039/.

Sep;57(9):983-5. Available at: http://www.

Accessed: 2014 Jul 3.

ncbi.nlm.nih.gov/pmc/articles/PMC3173411/.

11. Campos-Outcalt D, Senf J, Kutob R.

Accessed: 2014 Jul 3.

Comments heard by US medical students about

2. Bandura A. Social foundations of thought and

family practice. Fam Med. 2003 Sep;35(8):573-8.

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Vol. 9, Issue 3 – September 2014

Feature

What kind of doctor do you want to be? tackling the question every medical student gets asked By Scott Turcotte, University of Toronto, Med Class 2016

“So what kind of doctor do you want to be?” This is a question every medical student is invariably asked — and it can be incredibly difficult to answer. The process of selecting which specialty you will pursue is something all medical students must face. It is both thrilling and anxiety-provoking. The decision has important implications for all students, their families and friends, and the future patients they will treat. Five fourth-year medical students from across Ontario were interviewed for this article about their experiences when selecting a specialty, as well as for insight and tips for preclerkship and clerkship. Understanding what you enjoy and why To some medical students, the broad categorical options may seem fairly obvious: surgery versus medicine (or others such as pathology), patient population (full spectrum, pediatrics or geriatrics), and practice scope (primary care or specialization). Preferences for these broad categories will vary depending on the individual. Troy Ng from the Western University said: “I think the number one thing I would tell people is to be honest with yourself about what you really want.” Other less obvious factors include specialty-specific abilities to shape one’s practice and balance one’s life, as work hours and responsibilities will vary depending on each specialty’s specific requirements, and the different sub-cultures within each of the specialties. “I found every [residency] program to have its own characteristics, and so it’s about figuring out where you fit in,”

said Amanda Boxhill, from the Northern Ontario School of Medicine. If you’re fascinated by many different aspects of medicine, instead of being drawn to one or two specific specialties, you’re certainly not alone. Jena Hall from the University of Toronto notes that the educational material that is most interesting to an undecided student during lecture and/or problem-based learning may help direct their attention toward the specialty they truly enjoy. Location Once medical students have narrowed their focus down to a few potential medical specialties, the location of their residency will influence their life for the next two to five years, and their practice abilities thereafter (the process of residency matching is described on the Canadian Resident Matching Service website at www.carms.ca). Some factors to consider include: being in a large city versus smaller community; being specialty-focused or locationfocused (to be near friends and family); the educational quality of residency programs, and the relationship(s) different residency programs have among colleagues and program administration/faculty. For Victoria Pang of the University of Ottawa, ranking her desired program 22

was difficult because she felt torn between the best program for her and other factors in her life. “What I ended up ranking would probably be very different if I lived in a bubble without family, without a partner, and without other factors,” she said. Pang managed the issue by separately ranking a list of her desired residency programs on her own, and then collaborating with her partner, and revising her final match list in order to achieve the most ideal outcome for them both. The educational quality of specific residency programs is an important factor applicants must also take into consideration. In Canada, each program is accredited by a regulatory body — the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada — and the quality of the education is assessed. Of the many factors potential residents could inquire about with respect to the different programs, the ratio of service to education may be the most important as this influences workload and ability to learn during formative years. When considering a match, take each program’s social and professional atmosphere into account. The dynamics between residents and their colleagues, and between residents and program administration can be assessed while on an Vol. 9, Issue 3 – September 2014

elective or during an interview. Amanda Boxhill notes that it’s important to get to know the residents while you’re on elective, because they can tell you what they like and don’t like about the program. Job market and remuneration Another key factor many medical students are taking into account is the current job market for various specialties. Sean O’Loghlen of Queen’s University did not factor job availability into his decision to pursue his desired specialty (internal medicine). “Right now, I think it’s becoming more apparent that certain specialties are actually in pretty dire straits,” he said. A 2013 report from the RCPSC identified that 16% of new specialists and subspecialists cannot find work, leading many of them to obtain a subspecialist/fellowship education to become more competitive and/or to find temporary positions (known as locums). 1 Specialties that were identified as most affected were surgical and resourceintensive disciplines, such as critical care, gastroenterology, general surgery, hematology, medical microbiology, neurosurgery, nuclear medicine, ophthalmology, radiation oncology and urology. Although the job market will undoubtedly be different by the time current medical students complete their residencies, the report did note that surveyed residents reported inadequate career counseling and information concerning jobs. Therefore, it is essential for medical students to continually consider the uncertainty of the job market for some specialties when planning ahead. Regardless of the specialty, students should understand that each specialty has its own responsibilities and compensation models. The Canadian Medical Association website offers profiles for 38 different specialties, and presents information detailing practice setting, income and job satisfaction.2 Another factor students may wish to take into account is overhead expenses, which will also vary depending on specialty. A 2012 study from Petch, et al., reported on public payments to Ontario physicians and adjusted remuneration for overhead costs. 3 “You have to be really committed to the specialty,” said Hall. “If you don’t love it, then it’s not enough.”

Tips for medical students Preclerkship 1. Engage in multiple observerships and do them early in your education. They are low-stress at this stage of your career, and expectations are generally low. The novelty of a specialty or procedure can wear off over time, so taking this time to experience it before CaRMS is ideal. Personal anecdotes may be obtained from residents or staff to help you make your decision. 2. Go into clerkship with an open mind, as opinions and perspectives change with experience.

are not permanent. Residents have been known to change their professional direction by switching specialties within or between schools (warning: this can be met with resistance from program directors), and physicians have been known to re-educate themselves in other areas of interest later in their careers. Like all aspects of life, we evolve with age, and our individual experiences will impact the level of satisfaction we derive from our professions. As Troy Ng stated, “I think it’s different for every person. You just have to be honest with yourself.” References: 1. Fréchette D, Hollenberg D, Shrichand A,

Clerkship 1. While on electives, take a notepad with you to record names, contacts, first impressions, and additional info. 2. Once you know (or think you know) what you want to do, discuss it with family, friends, colleagues and mentors as soon as possible. This will make you a more competitive applicant. If you don’t have a mentor, try to find one in the respective field, do an elective with a member of the admissions committee, and/or perform research in the field. If you’re able, take advantage of electives at other medical schools as a way to demonstrate a willingness to relocate for residency.

Jacob C, Datta I. What’s really behind Canada’s unemployed specialists? Too many, too few doctors? Findings from the Royal College’s employment study — 2013. Ottawa, ON: Royal College of Physicians and Surgeons of Canada; 2013. Available at: http://www.royalcollege. ca/common/documents/policy/employment_ report_2013_e.pdf. Accessed: 2014 Jun 16. 2. Canadian Medical Association. Specialties: Canadian specialty profiles. [Internet]. Ottawa, ON: Canadian Medical Association; c1995-2014. [about 3 screens]. Available at: http://www.cma. ca/c3pr-specialties. Accessed: 2014 Jun 16. 3. Petch J, Dhalla IA, Henry DA, Schultz SE, Glazier RH, Bhatia S, Laupacis A. Public payments to physicians in ontario adjusted for overhead costs. Healthc Policy. 2012 Nov;8(2):30-6. Available at: http://www.ncbi.

Final words It’s important to note that these decisions

nlm.nih.gov/pmc/articles/PMC3517870/. Accessed: 2014 Jun 16.

Sean O’Loghlen (centre) of Queen’s University’s Med Class 2014, with friends (from left) Kaylie Stewart, Bonnie Shum and Sergei Reznikov, after their residency match day. 23

Vol. 9, Issue 3 – September 2014

Feature

Finances

When waste becomes life:

Residency and finances:

an introduction to umbilical cord blood banking

opting for a line of credit

By Wyanne Law and Aajab Abdulhussein, University of Ottawa, Med Class 2017

By Kaylee Bodnarchuk, University of Ottawa, PGY-2 psychiatry resident

the National Public Cord Blood Bank (NPCBB), a branch of caNADIAN blOOD sERVICES (CBS), was established in September 2013 to collect, process, test and store cord

I was fortunate to enter medical school debt free. After completing my

blood units after delivery for use by Canadian or international patients in need of a

undergraduate degree, I worked for two years before beginning medical school.

stem cell transplant. Dr. David Allan is the medical director and adjunct scientist at

What little money I saved during those two years barely covered the tuition and

the NPCBB, CBS, and HE explains the importance of umbilical cord blood banking.

book expenses incurred in the first month of medical school, and I quickly realized

1. How did you get started with the National Public Cord Blood Bank? My research on the regenerative capacity of umbilical cord blood derived vascular progenitors ties in closely with research at CBS on the development of novel cell products. My interest in transplantation and cell-based therapies was a natural fit for my role as a medical director of the NPCBB at CBS. 2. Why is it important to collect blood stem cells from the umbilical cord blood? Donor unavailability is increasingly problematic due to smaller family sizes in the last few decades, and greater multi-ethnic communities that give rise to more complex HLA-gene combinations. Umbilical cord blood banks are ideal for capturing this changing HLA diversity in real time, and it provides a source of blood stem cells that have a greater chance of meeting the HLA-matching requirements for patients of the future. There is an increasing need for alternative sources of blood stem cells, such as umbilical cord blood, which can be used in transplantation to treat patients with leukemia and other blood disorders. Umbilical cord blood is an excellent alter-

native to bone marrow when a matched sibling or unrelated donor is not available or cannot be identified. 3. What is the purpose of the National Public Cord Blood Bank? The primary goal is to bank close to 18,000 units of high quality cord blood units with high cell content. These are to be used by transplant centres here in Canada and around the world to treat patients with leukemia and other blood disorders who do not have a matched donor. 4. Private cord blood banks have existed for many years. What value does a public cord blood bank bring to patients who can afford private banking? Private or family banking allows families to store cord blood cells for their own family use. However, the chances of using cord blood units in family banks remains quite low, and it is unclear how this might change in the future if new applications for using cord blood cells emerge in mainstream medical therapy. Banking cord blood cells in NPCBB is an altruistic donation that may benefit a stranger in need in Canada or elsewhere if the unit is sufficiently matched and contains enough cells for a successful transplant. 24

5. Why should medical students and physicians support this initiative? Medical students are the physicians of the future. They continue to challenge and stimulate discussion within the medical community, and provide energy and enthusiasm in support of medical issues of the day. Discussing umbilical cord blood banking with patients and expectant mothers will help the NPCBB and other cord blood banks succeed in building an inventory that will serve the needs of Canadians and other global citizens. 6. How can medical students raise awareness about umbilical cord blood banking? Medical students can raise awareness within the medical community and beyond by educating parents regarding choices related to cord blood donation. This can be done by participating in awareness initiatives such as the one that is established at the University of Ottawa. Students can also discuss umbilical cord blood banking with mentors and supervisors during rotations in family medicine or obstetrics, particularly at collection centres affiliated with a public bank or collection hospital. Vol. 9, Issue 3 – September 2014

that for the first time in my life I would need to go into debt. After maxing out my student loans, it was clear that I would need additional funding to pay for my schooling and living expenses. A little research indicated a line of credit (LOC) would be my best option. When looking for a LOC, I explored all my options, and although I had been with my financial institution since I was five years old, it wasn’t my first choice. I wanted to partner with a bank that could understand and anticipate my needs as a medical student as I transitioned into residency. I asked friends what their financial institutions were offering for terms and conditions on their LOC, and if there were any other student promotions or offers I should consider. After considering the various options and information I had received, it was ultimately about the bottom line — I wanted to have as little debt as possible when I graduated, and this meant finding the lowest interest rate possible. Once that criterion was met, I chose the financial institution that I trusted to anticipate my challenges through residency, to understand my evolving financial requirements, and one that offered

specific services tailored to my needs as a future physician. The transition from medical student to resident came with new challenges in managing my finances because, although I now had the title of “MD,” I wasn’t yet earning the income of one. It is tempting to start spending money in anticipation of a staff physician’s salary, but in order to keep my debt from ballooning during residency, I budgeted according to my annual salary as a resident. Meeting with a financial advisor once a year has been the best strategy for managing my spending and maintaining awareness of my debt load. In preparation for these meetings, I evaluated my expenses and spending habits over the past year, which allowed me to recognize unnecessary expenses and to develop a budget for the next year. My financial advisor has been instrumental in providing advice according to my goals — whether they were to develop a strategy to decrease my debt load, or to focus on investment and saving. I have managed my LOC by spending within my means and remaining 25

aware of my total debt load. Once I overcame the startup expenses of residency (such as moving across province, purchasing a vehicle, and furnishing my new apartment), I have used my LOC as an emergency fund only. My strategy isn’t to worry about paying down my LOC during residency, but where possible, to refrain from further withdrawals. In making the interest-only payments on my LOC, I have ensured a stable balance and avoided paying interest on interest. To prevent over-borrowing and overspending against my LOC, I often make compromises to focus on my needs rather than my wants. However, all of my spending and saving efforts are done in moderation — residency doesn’t have to be made more difficult by going without a vacation or a little retail therapy when needed! Scrub-In’s Finances column is provided by MD Physician Services (a CMA-owned company), which offers tailored financial products, services and advice to medical students, residents and physicians. For more information, or to speak to a financial consultant, visit md.cma. ca, or call 1.800.267.4022. Vol. 9, Issue 3 – September 2014

Inter-relationship of sicca symptoms, autoimmunity and systemic sclerosis

Medical student research highlights

By Ambika Gupta, University of Ottawa, Med Class 2015

Long-term psychosocial functioning in women undergoing bilateral prophylactic mastectomy By Lucy Li, University of Toronto, Med Class 2016 Prophylactic mastectomy has been shown to reduce the risk of developing breast cancer by more than 90% in women with a BRCA1 or BRCA2 mutation. However, few studies have examined the long-term psychosocial implications of the various types of prophylactic mastectomy available to women, which is why I wanted to focus on this topic for my research project. Through my pre-clerkship training, I’ve developed a keen interest in women’s health, and was fortunate to conduct my research at the Familial Breast Cancer Research Unit at Women’s College Hospital. Prior to my medical training, my research background was in cell and molecular biology, as well as evolutionary biology. This research project was my first foray into clinical research. There are various types of prophylactic mastectomy that can be performed; options may include the removal of the nipple and/or areola, along with the breast tissue. As a result, women are often concerned about the final cosmetic outcome, as well as retention of breast sensation, and opera-

tive and post-operative morbidity. Our research sought to evaluate whether the type of bilateral prophylactic mastectomy would impact on the long-term psychosocial functioning in women who have undergone this procedure. Patients were retrospectively identified and sent validated questionnaires that assessed different aspects of psychosocial functioning. The preliminary findings suggest that the type of prophylactic mastectomy — skin-sparing, nipple-sparing, areola-sparing — does impact on the patient’s long-term satisfaction and psychosocial functioning. Although we are still in the process of recruiting patients, we believe that the impact of our study will be quite significant. We hope that this study will enable physicians to provide more accurate pre-operative counselling to women considering prophylactic mastectomy, and highlight the importance of its psychosocial effects. After all, the psychosocial impact of a procedure is just as important on a patient’s overall well-being as its oncological safety. I presented this research last May at the 15th Annual Meeting of the Ameri-

can Society of Breast Surgeons, held in Las Vegas. The conference had more than 1,500 participants, and the presentations on the latest surgical techniques, controversies, and landmark clinical trials enabled me to gain a better understanding of the current advances in breast disease research. I hope to apply the skills and experiences from my research to my medical practice in the future.

We recruited 194 SSc patients (n=26 males, n=168 females), of whom 63.9% reported dry mouth, 52.1% reported dry eyes, and 39.2% of female patients reported vaginal dryness. Our preliminary analysis suggests that a subset, which consists of the limited cutaneous SSc patients with anti-centromere antibodies, appear to have an increased burden of ocular and oral sicca symptoms, but are less likely to have interstitial lung disease. Sicca symptoms are common in SSc patients. Clinicians should ask patients about sicca symptoms because they are important determinants of quality of life. Participating in research is critical to my training and development as a future physician. Research is crucial to provide patients with the best, evidence-based care. Clinical decisions are continuously influenced by advances in research. At my level of training, I believe that it is vital to understand the research process — how to review and interpret literature and how to understand the stages of experimental design, data interpretation and communication. I became interested in rheumatology because I have an interest in immunology

and I find the pathophysiology of autoimmune and inflammatory diseases very fascinating. Rheumatology is a very exciting area of research because of many recent advancements involving biologics and other therapeutic treatments. Last February, I had the opportunity to present this research at the Canadian Rheumatology Association Annual Scientific Meeting. I will also be drafting a manuscript for peer-reviewed publication, and plan on continuing research activities throughout my medical education and into my career.

Obstetrical and fetal outcomes in patients with rheumatologic disease By Vidushi Khatri, Western University, Med Class 2015

Ontario medical students interested in having their research featured in a future instalment of Medical Student Research Highlights can visit: www.oma.org/MedicalStudents/Pages/ScrubIn.aspx to access the application form (at the bottom of the page). For more information, please email: [email protected]

26

Last summer, I became involved with a rheumatology research project entitled, Inter-Relationship of Sicca Symptoms, Autoimmunity and Systemic Sclerosis. Sicca symptoms are a combination of dry eyes and dry mouth that occur due to decreased exocrine gland function. The research focused on understanding the various presentations of Sjögren’s syndrome in patients with systemic sclerosis (SSc): serologic, ocular, oral and extra-glandular manifestations. At present, the relationship between ocular and oral sicca symptoms, autoimmunity and SSc is poorly understood. Knowing these relationships can assist physicians in treating patients with concurrent SSc and sicca symptoms more successfully. We performed a cross-sectional study of consecutive SSc patients attending the Toronto Scleroderma Program at Toronto Western Hospital, Mount Sinai Hospital, University of Toronto, using patient self-reported and physician-completed questionnaires, based on the Sjögren’s International Collaborative Clinical Alliance questionnaires.

Vol. 9, Issue 3 – September 2014

study to quantify obstetrical and fetal outcomes for RA patients exposed to new biologic agents during the peri-partum period. When completed, the study may have the highest sample size of any study in literature that examines the effect of drugs on RA patients, shedding light on the validity of current counselling. This exciting sub-specialty niche provides innumerable opportunities to become further involved. For instance, I recently returned from the Canadian Rheumatology Association Annual Scientific Meeting in Whistler, British Columbia, where I gave an oral presentation regarding Empirical Treatment of Dermatomyositis (DM) in a Pregnant Patient with Intravenous Immunoglobulin (IVIG). Although IVIG is still an experimental treatment for DM in the peri-partum phase, Dr. Pavlova has used it to manage several pregnant patients with the disease in Hamilton. We plan to follow these patients and eventually publish a case series. Rheumatology is a fascinating and diverse field, as its manifestations touch nearly every medical specialty. Contributing to a subject area that is little understood is highly satisfying as every small laboratory or clinical discovery can have major impacts on patient care. As I immerse myself further in this field, I hope my research will help the thousands of Canadian patients affected by rheumatologic conditions to make crucial decisions in family planning.

The effect of rheumatologic diseases during the peri-partum stage is ill-documented in literature. Current understanding is limited to case reports and small retrospective case control studies. The scarcity of data has resulted in rheumatologists and obstetricians alike struggling to provide counselling to patients with rheumatoid conditions. It may be surprising that the answers to fundamental questions like disease course, adverse effect profile, and immunomodulator safety in pregnancy are not yet well established. However, with the exception of rheumatoid arthritis, the incidence of many rheumatologic conditions is rare. Rarity of incidence is further compounded with poor disease control, contributing to low numbers of reported pregnancies. Indeed, it is only in the last decade (with the advent of new immuno-modulators) that patients have been able to obtain effective control of their disease and have successful pregnancies. The majority of my research in obstetrical rheumatology is centred on working with Dr. Viktoria Pavlova, a rheumatologist and researcher at McMaster University, and the rest is with the Ontario Biologics Research Initiative (OBRI) team. The OBRI is a large Ontario-wide registry of thousands of patients with rheumatoid arthritis (RA). We are developing a prospective 27

Vol. 9, Issue 3 – September 2014

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