Into Africa: The Epic Adventures Following Gut Feelings

Dr. Louis Liu, Head of Gastroenterology, University Health Network and Sinai Health System, University of Toronto

May 12, 2017

Imagine, you have finally settled into a secure academic position at a prestigious university, doing what you love to do in medicine and teaching, at the peak of your career in one of the greatest metropolitan cities in the world. You invested more than a decade of post-secondary education, survived gruelling call nights, passed certification and licensure examinations, won praise from mentors, and now contribute meaningfully to provide health care and medical education in your local community. What would it take for you to leave it all behind for a month, and travel to a place unknown, all because someone said other people need your help?

Inspired by “Into Africa: The Epic Adventures of Stanley and Livingstone”, Dr. Louis Liu took us on his journey to Ethiopia, where he rediscovered passion and humility. Where he believes he learned more from the people he went to help, than they may have learned from him.

Through the Toronto Addis Ababa Academic Collaboration (TAAAC) between the University of Toronto and its affiliated Academic Hospitals, and the Addis Ababa University, many of our specialists travel to Ethiopia to teach and co-build their medical graduate education programs. And so began Dr. Liu’s epic adventure.

When he first arrived in 2009, Ethiopia had a population of approximately 85 Million, with a median age survival of 46 years. It was supported by only 2 gastroenterologists, 1 of whom was about to retire. A quick survey of the land was reassuring – Addis Ababa is situated at high altitude, has no malaria, and is safe. But where to begin?  Could he take the easy way out and bring the residents to Toronto to teach them? It was quickly apparent that would backfire. The epidemiology of disease is vastly different. We don’t see the same diseases. While there is a lot of liver disease, it is disproportionately represented by schistosomiasis and hydatid cysts, considered rare back on our continent.  Not to mention, it is never sustainable to train people outside their own environment without building the local infrastructure to support the skills acquired.

Instead, he stayed there and focused on curriculum design, tailored to the local needs.  He asked: What are the needs, the challenges? The medical trainees were strong in book knowledge. This was apparent as he sat through their didactic general medicine case discussions. He was humbled to become a learner again, reaching back to first principles to remember the core medicine, yet he observed that they lacked skills to move beyond the classroom to the bedside. Formal assessment practice was underdeveloped. This is where he found he could contribute and leave an impact. Each year, Dr. Liu returns to Addis Ababa with excitement and determination to continue building on the strong collaboration between our Universities. The successes could not be achieved alone. The GI Training Program is co-lead by Dr. Jordan Feld. Since 2009, he has gone to Addis Ababa with two GI residents, one GI fellow and seven GI faculty. Here is part of his legacy:

• He taught trainees how to translate book knowledge to the bedside
• He implemented evaluation tools based on the Royal College of Physicians and Surgeons of Canada, adapted to their local needs.
• They introduced their first OSCE for resident promotion.
• They graduated three classes including 11 graduates into seven new full time University faculty members, two affiliated faculty members, and two community practitioners.
• He employed diplomacy and politics:
• When he first arrived, they could not treat Hepatitis B or Hepatitis C. With the increase in knowledge and working with the local authority, the Ministry of Health is now providing the resources to treat both Hepatitis B and C.
• Malnutrition was a significant problem - they were able to advocate successfully for increased population level nutrition funding for admitted patients.
• The only treatment for inflammatory bowel disease was steroids – he has started working with the local authorities to develop local treatment guidelines for steroid-sparing agents when the agents become available
• Resources were lacking – he helped raise $1 Million-in-kind to purchase high definition endoscopy equipment, and established the first endoscopy training program in Ethiopia.
• He helped them build an administrative structure to support the division and training programs.
• He forged collaborations with a Norwegian group to set up abdominal ultrasound and plans to develop therapeutic options to liver cancer

The most poignant surprise? The beautiful people and culture – the resilient, smiling and proud, though poor and ill people are grateful for the care the group provides when they arrive. The trainees and new faculty feel a sense of belonging to the greater academic and medical international community in contrast to isolation.

Dr. Liu accomplished great things in a short time since he first travelled to Addis Ababa. It was not alone. Many of his colleagues from his division with diverse expertise now travel with him. The Gastroenterology program offers invaluable educational electives for their fellows to travel with the group. Improvements to the structure and delivery of GI training and health care services was successful because of the respectful collaborations with the local stakeholders to co-create a model, not to unilaterally transplant one based on our existing model back home.

The future for the TAAAC GI is moving quickly. They are hoping to begin a live journal club, but are looking for solutions to the limited internet. They are building the local GI society, which now has around 30 members. Lastly, there are opportunities for their new Faculty members to attend conferences opening doors to international contact and collaboration.

Aiming to discover the source of the mighty Nile river, Stanley’s chronicling of Livingstone’s nine year epic adventures was embarked on with "alarming foolishness, intense courage, and raw human achievement.” While Dr. Liu’s 21^st Century travels are no comparison to that intensity and danger, they are out of his usual comfort zone, from which the greatest rewards are found. Dr. Liu sums up his personal reflections with familiar lesson, reminiscent of those from Dr. Robert Fowler’s #CEEPAoM talk, “Art of Medicine, Unplugged” (October 25, 2016):

• Value opportunities - Accept uncertainty and take a chance
• Have a passion and act on it – But, be an active listener
• Ask for help - Identify allies within your local community
• Do not accept the status quo -  Overcome barriers with solutions
• Make a difference - Give back 

BIO - Louis Liu, MD, PhD, FRCP(C)

Dr. Louis Liu is Director of the Division of Gasteroenterology at UHN/SHS and the Director of the Clinical Motility Unit at UHN. In 2009, he established the Neuro-gastroenterology and Motility Fellowship Training Program at the University of Toronto, where he holds an appointment as Assistant Professor in the Department of Medicine. He is also lead for the GI Residency Training Program at Addis Ababa University in Ethiopia. Dr. Liu is the Chair of the Admissions Committee for the Canadian Association of Gastroenterology.

Without compassion there is no healthcare

Dr. Brian Hodges, Professor, University Health Network, University of Toronto

Tuesday April 18, 2017

Posted by Nadine Abdullah, MD, MEd, FRCPC

Could you imagine a simulation robot providing you with impeccably perfect care, but without compassion? Or compassionate but inefficient care from a real live health care provider without the possibility to cure your disease or improve your health? Which is more valuable to you? Care, or compassion? Is it necessary to compromise and choose only one? What if you could have both?

In the age of expanding artificial intelligence technology and deep learning systems, it is not so far-fetched to ask these questions. The answers, we should contemplate before we re-imagine healthcare to incorporate innovative technologies that could realistically replace human beings, eliminating the human touch from healthcare delivery.

We were delighted to host Dr. Brian Hodges for our Art of Medicine Lecture series to address the relevance of compassion in healthcare. At the core of our relationships with patients, we are each individuals with a basic human need for interactions based on emotion and compassion. Patients feel more satisfied with compassionate care, and physicians derive more satisfaction from their work when providing care with compassion. At our most vulnerable, that need for compassion is magnified, not only as patients seeking care, but as providers working in an environment where tragedy and loss of life are witnessed not inside a vacuum, but with lasting impact in all aspects of our lives.

If we take a step back from our work environment, and reflect on our relationships within that complex and often-chaotic environment, it is not hard to see that we have created an abnormal arrangement between healthcare providers, and patients. Immersed in completing forms, reviewing electronic charts for data, strapped to technological gadgets to search for information, we barely speak to one another, let alone engage in meaningful conversations with our patients.

How can we think of compassion, so it maintains a primal role as we transform healthcare into an integrated system of technologies? Dr. Hodges helped us envision compassion through a framework that sees it as a behavior, a competence, a value, and a resource.

Behaviour: One way to configure compassion is as a human and professional behavior. Our behavior defines our compassion, or lack of it, as much as our words. When we previously explored the early loss of empathy in medical students in Dr. Catherine Yu’s talk “There’s no Billing Code for Empathy – Graphic Narratives in Medical Education, February 9, 2017”, we touched on the heavy weight of the hidden curriculum and its role in modeling undesirable behaviours, and reinforcing lack of compassion in favor of efficiency in care. Artificial intelligence will be able to take over cognitive tasks for diagnosis and treatment. The technology is there already, ready and waiting to be integrated into our system. The possibilities to maximize efficiencies in our system are endless. But we know the push to efficiency is one of the greatest facilitators of compassion loss in trainees. So we have important choices to make now. How do we use the time and space gained from efficient systems? The benefit of automated processes moving us away from time-consuming tasks and toward more patient contact time is appealing. Can we seize and utilize it to return to the core of compassionate care?

Competence: A deliberate artifact of our training is how our assessments drive learned behaviours, such as taking an accurate history, or performing the steps for a physical exam maneuver. Do we add “compassion” to the checklist of performed tasks on an OSCE station? Do we incorporate a narrative assessment of our student’s compassion longitudinally over the training period to reinforce its prime location in the development of professional identity? If we frame compassion as a competence, we can explicitly shape compassion as an expected professional component of care, placing it in the forefront of our curriculum giving it equal weighting to knowledge and technical skills. Evidence from advanced cancer patients shows that patient's perception of compassion as a competence in health care learners is evident, and that teaching methods including patient-centered communication, self-reflection exercises, and compassionate role modeling can be used to nurture compassion from an innate quality, to sustained practice.

Value: In our institution, we have a long tradition of recognizing, valuing and rewarding compassion, I daresay more so than we do for performance exams now that we have done away with grades in favour of pass/fail. The coveted “Golden Stethoscope Award” awarded for “demonstrating a combination of academic achievement as well as attributes of a humane and compassionate clinician” is, in my mind, the most valuable recognition of professional development in our students. In post-graduate medical education, a similar award, the Sopman Humanitarian Award is dedicated by peers and teachers to trainees who “encourage characteristics of humanity, compassion and understanding along with the ability to communicate with patients and families.”

Resource: But why stop there if we value compassion. Compassion is a finite resource that needs to be refueled. Burnout strips us of compassion, and is widely prevalent throughout all stages of practice. If we are to sustain compassionate care throughout decades more of practice, as technology emerges that may replace much of our care, should we not equally recognize, value, and reward compassion in the very teachers who seek to espouse it in their students? If we are to maintain the compassion that drove us to the varied healthcare professions, we must attend to the moment in which we are providing care, without distraction from the varied tasks that pose physical, temporal, and emotional barriers between healthcare provider and patient. We can do so by advocating to build system-wide processes that foster individual resilience, rather than placing the onus on the individual health care providers for their own wellness. This is key to maintaining the resilience that human beings need to deliver compassionate care.

Moving forward, rather than debate the benefits and perils of expanding technology in healthcare, I am challenged to re-frame its creep, and instead take advantage of it. During Dr. Hodges talk, I was reminded of my initial reaction to the nuisance of point-of-care ultrasound that crept up at the bedside in the hands of my trainees. Rather than see it as a cumbersome tool that hinders the human interaction, we can re-frame it as a tool to connect, to lay hands on the patient, and use the images to demonstrate to the patient what we are seeing together, what it means, and how we will manage it. In this way, we can see the technology as a means by which to enhance the therapeutic relationship, by owning the investigations and findings, sharing information and decision-making, rather than clicking the test from a menu in the computer and seeing the patient carted off to another department to be treated by someone else.

Virtual visits, remote monitoring, holograms – the stuff of Star Trek – have already begun making their way into health care. Make no mistake; this was not a talk for the future, but for how we can prepare now to shape the future to be, as patients and healthcare providers want it to be, as these tools percolate through our healthcare delivery systems. Before posting this, I listened to our President and CEO Dr. Peter Pisters give a visionary talk at Medical Grand Rounds on “The Rapidly Changing Health Care Landscape and the Opportunities Ahead”. It was eerily reminiscent of the future Dr. Hodges predicted for us, and a reminder to urgently capitalize on this era to reinforce that “without compassion, there is no healthcare.”

Resources:

Humanism, compassion and the call to caring

From Detached Concern to Empathy: Humanizing Medical Practice

Compassion training in healthcare: what are patients’ perspectives on training healthcare providers?

Without compassion, there is no healthcare

Bio – Brian Hodges, MD, PhD, FRCPC

Brian D. Hodges is Professor in the Faculty of Medicine and at the Ontario Institute for Studies in Education at the University of Toronto; the Richard and Elizabeth Currie Chair in Health Professions Education Research at the Wilson Centre and Executive-Vice President Education at the University Health Network (Toronto General, Toronto Western, Princess Margaret, Toronto Rehab Hospitals and the Michener Institute). He is a practising psychiatrist and teacher. His research focuses on assessment, competence, compassion and the future of the health profession. His work has been recognized with the Association of American Medical Colleges Flexner Award (2015) and the Karolinska Institutet Prize for Research in Medical Education (2016).

How Canada botches scientific misconduct investigations: A physician-journalist's perspective

Dr. Miriam Shuchman, Associate Professor of Psychiatry in the Faculty of Medicine, University of Toronto

Friday March 31, 2017

Posted by Nadine Abdullah, MD, MEd, FRCPC

Today, we took a departure from our previous talks to examine a less-commonly discussed side to the scholar and professional CanMEDS roles in medical education: scientific misconduct. We were excited to have as our guest speaker physician and renowned investigative journalist Dr. Miriam Shuchman, who has written extensively on the issue of ethics in research and policy. She led us through a discussion of scientific misconduct, the subject of her recent publication in which she calls for improving the investigation process of scientific misconduct allegations in Canada. I have reflected on the great content of her talk, its place in medical education, and the unique role that medical journalism has played bringing this issue to light.

Scientific misconduct in Canada is investigated under the Tri-Agency Framework: Responsible Conduct of Research. It comprises the Canadian Institutes of Health Research (CIHR), the Natural Sciences and Engineering Research Council of Canada (NSERC), and the Social Sciences and Humanities Research Council of Canada (SSHRC) (the Agencies) with a mandate to ensure commitment to responsible research conduct. The framework sets the standards for research integrity and expectations of individual researchers and institutions in promoting and adhering to a positive research environment. It outlines processes for addressing and reporting allegations of breaches of conduct.

Since its recent inception in 2011, filing of allegations has risen, with severity varying from minor inadvertent breaches to plagiarism and outright falsification and fabrication. One reason for this wide spectrum is that Canada has chosen a broad and imprecise definition that equates egregious intentional, conscious misconduct, with unknowing, unintentional deviations from ethical practice. This, combined with inherent problems in the investigation process including bias, lack of oversight, transparency, and due process, and an extremely long process for deliberation, has led to a system that fails to uphold the public trust and support new researchers. The myth that "only bad apples get in to trouble" is unfortunately false because of the definition’s breadth, with potentially fatal career repercussions for those who act in good faith and could instead have received education or remediation for innocent deviations.

An even more serious problem exists with not identifying and immediately punishing the truly egregious cases of falsification or fabrication of research data. The Chandra case from Memorial University was investigated by the institution, but not until mainstream media uncovered the story were his fraudulent publications retracted and he was publicly exposed, stripped of his Order of Canada, and shunned from the medical community. A celebrated pediatrician and researcher in nutritional immunology, Chandra was found guilty of outright fraud in two studies; one purporting the benefits of a specialized formula to prevent allergy in infants, and the other purporting the memory benefits of his patented vitamin and mineral supplement. The case with the greatest societal fallout from egregious scientific misconduct is that of Wakefield from the UK, who fabricated studies linking autism to a fictitious gastrointestinal disorder and the MMR vaccine. The impact of falsifying a link between autism and vaccinations took too long to be addressed by the institution and medical journal, leaving irreparable damage to the public trust in science and medicine. This undeniably caused vaccination rates to fall, loss of herd immunity, and a resurgence of previously controlled or eradicated infectious diseases responsible for the deaths of young children and susceptible adults.

Why is this relevant to medical education? Two reasons:

First, as a medical educator and non-researcher, the width of the net that captures misconduct in Canada came as a surprise. While there is a universal code of research conduct, specific policies vary between institutions. Young researchers may not be aware of minor digressions that would qualify as misconduct. For example, copying sections of their own published work in subsequent papers to avoid redundancy, in some jurisdictions could count as plagiarism. More shocking is the immediate finding of guilt by association of shared authorship with someone found to breach ethical conduct, even if the fraudulent behaviour was not their own. The immediate professional consequences on the researcher for being found guilty of research misconduct can include retraction of research papers, termination of employment, requirement to repay grant funding, and loss of a licence to practice medicine. I do not think we prepare our trainees to avoid or mitigate these risks. A Cochrane review showed there is no evidence that education prevents fabrication or falsification, or promotes integrity in research. Those determined to be dishonest, driven by the academic pressures of achieving high volumes of high impact publications, will likely not be deterred by any form of education. However, some small studies have found a reduction in plagiarism with educational programs for trainees if accompanied by technological tools. I do wonder if education can attune trainees to plagiarism, and other less obvious deviations from ethical standards. As a start, undergraduate and postgraduate curricula should incorporate the topic of scientific misconduct into the curriculum to heighten trainees' awareness if they choose a career in research, as many do. We need to teach medical trainees about research codes of ethics, writing skills, and pitfalls to avoid unintentional deviations from the expected standard. In between the extremes of inadvertent plagiarism and outright fraud, it is well described that minor digressions can be tempting when results are rewarded, and can “open the doors to the slippery road from minor digressions to outright misconduct.”  Education may be able to teach trainees how to spot unethical conduct by collaborators and supervisors, and give them an awareness for their own weaknesses that can lead them to break the code. Educational programs should teach trainees how to handle data and authorship disputes and hostilities, and there should be a mechanism in place for seeking anonymous advice, with an appointed ombudsperson to guide them through a complaints process. I think all of this is possible. In contrast, there will always be dishonest researchers. While it may not be possible to eliminate the risks of association, we can give trainees the tools to identify and steer themselves away from associating with the real bad apples.

Second, whose responsibility is it to teach our trainees on this topic? Judging from the statistics, if not taught with care, I fear our promising and emerging leaders in medical research will choose a different path if they see the risks as unavoidable in research. The culture of academic medicine rewards high impact work, and the recognition and reward of disseminating one’s practice-changing work is powerful. Dr. Shuchman highlights, "Just as publishing builds a scientific career, retractions dismantle it." Whether the drive for success is perpetuated by clearly articulated expectations or a hidden curriculum, we need an explicit curriculum to model ethical research practice. How else can we hope to encourage trainees to enter research careers despite the risks, and adequately prepare them for a successful, fulfilling career? Educators do need to share ownership with researchers teaching about scientific misconduct, but until now, it has been largely absent from our curricula. This talk prompted me to consider the role that medical journalism could play. While the researchers and educators have not taken this on, it is fascinating to consider that the issues presented in Dr. Shuchman’s talk today and her published work could be the platform for a curriculum. There is a role for a different lens and a different way of knowledge informed by investigative journalism, to lead the educational curriculum in scientific misconduct. Talks like this one provide more opportunity for trainees to be exposed to this perspective.

I was first drawn to the topic of scientific integrity after reading Dr. Shuchman's earlier investigative articles. Universities and medical journals have historically failed in their prompt responses to egregious scientific misconduct, leading to great public mistrust. Mainstream media has played a critical role in exposing cases like those above. They also have reported inaccurately, sensationalized information, and misrepresented the truth in others. There are pitfalls and limitations in leaving scientific misconduct in the hands of the lay media. The dissemination of scientific research findings, and the subsequent questions of fraud, should be led by those trained in research and medicine. Dr. Shuchman argues that both researchers and the media share the responsibility for accurate communication to the public, and in her 1997 paper, she proposed ways to improve health news reporting, focusing on four problem areas: sensationalism, biases and conflicts of interest, lack of follow-up, and stories that are not covered. I was still a medical student when this was published. Have we progressed since 1997?

The integrity of medical research requires skills not traditionally taught in medical school and residency training programs. Editors of medical and scientific papers will readily offer that authors lack writing skills. Research integrity requires robust writing skills to avoid inadvertent plagiarism, and knowledge of politics that governs research institutes and journal oversight committees to understand the local policies, and the mechanisms for reporting discrepancies. Medical journalists can be agents of change in medicine and health care. This talk has certainly highlighted for me the gaps in medical education developing scholars and professionals armed with the knowledge and skills to uphold scientific integrity.

Thanks to Dr. Shuchman for bringing this topic to the forefront of our GIM CTU Art of Medicine rounds through her unique lens. I am inspired, yet again, to keep questioning how we can improve the teaching of our intrinsic CanMEDS roles in medical education.

Resources:

Litmus Test. Scientific misconduct in Canada can include outright plagiarism and fraud as well as minor unintentional mistakes.

Tri-Agency Framework: Responsible Conduct of Research

Cochrane Review: Preventing misconduct and promoting integrity in research and publication

Stopping the Slide to Research Fraud

Medical Scientists and Health News Reporting: A Case of Miscommunication

Journalists as Change Agents in Medicine and Health Care

Bio – Miriam Shuchman, MD

Dr. Miriam Shuchman is an Associate Professor of Psychiatry in the Faculty of Medicine, University of Toronto. She is an award-winning journalist and former national correspondent for the New England Journal of Medicine who writes on medicine and bioethics for journals and magazines. She has a clinical practice at the University of Toronto Scarborough Health & Wellness Centre.

"There's no billing code for empathy" - Graphic narratives in medical education

Dr. Catherine Yu, Associate Scientist, Li Ka Shing Knowledge Institute

Thursday February 9, 2017

Posted by Nadine Abdullah, MD, MEd, FRCPC

(Photo source: annals.org)

This week we talked about empathy. Can it be taught? Can it be learned?

Dr. Catherine Yu shared with us a surprising finding that sparked her interest in this area: Empathy loss in medical students occurs as early as second year, before they even engage in patient care, possibly due to the stress of rigorous medical training. Dr. Yu and her colleagues embarked on research to see if this trajectory can be altered using medical narratives early in medical training to humanize the patient experience as they learn the medical science of disease.

They created graphic comics depicting a patient’s relationship with his doctor, learning about his new diabetes diagnosis, lifestyle modification, and insulin administration. Watching these graphics, you get a real sense of how exhausting his life is, and how he changes over the course of a year, failing to keep up with the required changes. In their study showing these graphic narratives to medical students, they showed that they had impact on their perception of the patient experience, and helped them understand the challenges of chronic disease management. Through critical discussion of the graphics, they see the changing posture of the physician becoming looming and ominous; the patients deteriorating diet, thrown away prescriptions and missed medications, and change in affect toward despondence, gloom and abject failure in managing his disease, the students felt a sense of what it is like to be in his shoes. They felt empathy. They described a sense of renewal, and felt that periodic reminders of empathy are required to reflect on why they came into medicine in the first place. It was an antidote to empathy loss that comes with exhaustion.

For those who doubted, it seemed like maybe we can teach empathy. Whereas most felt that the lecture format to traditionally teach empathy has no impact, some felt that a formal curriculum using creative Narrative Medicine methods such as the graphic comics we viewed can be an efficient and fun way to teach empathy, and can easily be interspersed throughout the formal curriculum as reminders. Time was not a barrier.

Many in the audience felt that the hidden curriculum had the greatest potential for teaching empathy. Students learn empathy both explicitly and implicitly from the clinical environment. This can either lead to empathy loss where empathic behaviours are discouraged, or promote empathy growth when educators and coworkers model and positively reinforce empathic behaviours. One student in Dr. Yu’s study cited being mocked on a surgical rotation for taking time out to bring water to a thirsty patient. The student internalized this as a lesson how not to behave, and a message that there is no place for empathic behaviours. Where these messages exist, students feel empathy loss. However, the positive reinforcement of empathic behaviours gives them permission to feel and behave empathically.

Is it sufficient to teach empathy passively through role modeling, or does it require active labeling and explicit reinforcement? When I take time to listen to a patient’s story on morning rounds and recognize how complicated it is for them to live with chronic disease, I do not label it as “This is empathy.” When I hear from my students that I demonstrate compassionate care, and that this has affected their learning experience and they want to emulate this, I am implicitly teaching empathy. I have a colleague who takes a different approach. On morning rounds in the ED he would open patient’s juice containers, butter their toast, and then explicitly tell his team “This is patient-centred care.” He points out how impossible it is for a frail patient connected to wires and tubes, with arthritic hands and weakness even to prepare to eat the tightly sealed food. He is teaching empathy. Is the explicit labeling necessary?

In contrast, a few residents expressed that we cannot teach empathy at all, but that students can fake it. One went as far as saying that most of being a doctor is acting, and that you have to be able to fake it. The attending physicians I later polled shared my shock at this remark, but the trainees did not. In times of long hours and exhaustion, they feel they sometimes do have to “fake it ‘til you make it”. They relayed a sense of frequently feeling burnout and emptiness, and having nothing left to give. One of the students in Dr. Yu’s study precisely echoed this sentiment. While they feel genuine in their empathy most times, when particularly stressed, they choose to fake it rather than the alternative, to disengage and not even try, and in their minds, provide worse care. I do not think they are wrong. All of us experience stress and burnout. It requires a mature ability to self-monitor, and if the need to fake it persists, we need to address the burnout and re-calibrate.

This reminds me of the children’s book “How Full is Your Bucket?” The concept is in being kind to others, we fill their bucket with empathy and in so doing we fill our own. Surrounded by a clinical environment with interdisciplinary health professionals who embody empathic care, seeing how each contributes to the care of the patient with the goal of improving their experience and clinical outcome, you cannot help but feel refueled and ready to join in to do the same with renewed energy. Setting an empathic clinical learning environment with professional behaviours when interacting with one another is a large part of the hidden curriculum that teaches empathy, and helps prevent empathy drain.

But empathy is beyond being kind. In fact, some argue we should not even be teaching empathy at all. It may make you and your patient feel good, and improve the likelihood of adherence to a treatment plan and success, but what really makes a difference in patient care is using our understanding to effect change. Emotions can get in the way of acting. Humanistic medicine utilizes our empathy and compassion as agency to effect change in individual patients and beyond to the greater population. I would disagree that we should not teach empathy, but on its own, it does not suffice. It is a starting point from which to care enough to act as an agent of change through advocacy. One senior physician in the audience included this in the definition he offered for empathy, and it is this view that is most consistent with humanistic care. It may be semantics, but as educators, we should be mindful that whichever way we might teach empathy, it is not just for the sake of improving patient satisfaction and adherence. It is ultimately to advocate for change to improve the health of our patients.

In answer to the question, can we truly teach empathy, in so much as we can articulate what professional behaviours demonstrate compassion and understanding of the patient experience, and make change to improve patient care, I think the answer is yes. For those who firmly believe we cannot teach empathy, I wonder if what they mean is we cannot make students empathic if they are not empathic to begin with. If a doctor is putting on an act and not authentic, patients will sense it. For those who begin empathic, we may be able to reinforce characteristics that already exist naturally in preselected students who have chosen a career path based on their inherent empathy. If this is the case, I think we are merely channeling their humanistic characteristics, providing context and re-enforcing what is already there. It requires attention to the formal and hidden curriculum, the clinical environment, implicit and explicit role modeling, and it needs periodic reinforcement.

Resources:

“There’s no billing code for empathy” - Animated comics remind medical students of empathy: a qualitative study

Annals Graphic Medicine - The Daily Grind: A Day in the Life of Someone Living With Diabetes

Annals Graphic Medicine - Not the Needle! A Day in the Life of Someone Living With Diabetes

Multimedia Learning -- Back to the Drawing Board?

Bio – Catherine Yu, MD

Dr. Catherine Yu is a Staff Endocrinologist at St. Michael’s Hospital, Associate Professor of Faculty of Medicine and Dalla Lhana School of Public Health, and Associate Scientist in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital. After completing her undergraduate and postgraduate training in Internal Medicine and Endocrinology at the University of Toronto, she then completed an MHSc in Public Health, focusing on the role of education and behavior change in knowledge translation.

Specifically, her research focus is on the care of the patient with diabetes in the context of a health care team, revolving around the role of integrative health informatics tools, patient and clinician education and behaviour change in improving quality of care. In this regard, she has been Principal Investigator and Co-Investigator on several CIHR-funded projects.  In addition, she is the Chair of the Clinical Practice Guidelines Dissemination and Implementation Committee of the Canadian Diabetes Association, in which role she has developed evidence-based and innovative strategies to put guidelines into practice across Canada.  

#Social Medicine – A review of social media and the CanMEDS roles

Dr. Anju Anand, Assistant Professor of Medicine, University of Toronto

January 20, 2017

Posted by Nadine Abdullah, MD, MEd, FRCPC

(Photo credit wordpress.com)

Ready, set, tweet!

What a tweet it was!

Ok, enough bad puns. It speaks to my initial discomfort with the world of social media. If anyone could draw me out of my fear and into a new realm of embracing social media in medical education and patient care, it was Dr. Anju Anand (@thelungdr). We were thrilled to have Dr. Anand speak about social media in the context of the CanMEDS roles. From Medical Expert, to the intrinsic roles of Communicator, Collaborator, Leader, Health Advocate, Scholar and Professional, it touches on every aspect. The take home messages? Social media use in medical education is essential, we must use it professionally, and Twitter is our greatest forum. Here's how (in more than 140 characters):

1) Promote patient care: With the wealth of un-vetted misinformation on the internet, we must engage to make accurate information available. We can communicate directly with individuals or patient groups about a medical topics and provide opportunities to share online resources with them in the office, and at home. Dr. Anand's personal success in the Cystic Fibrosis community is a website which provides accessible, accurate and timely information, educational tools, the latest research, and inspirational stories to the patient community.

2) Promote greater public health: The most industrious use in  I have seen is the dissemination of patient education materials in the form of whiteboard talks. Toronto's own family doctor Dr. Mike Evans is well-known for his YouTube whiteboard talks on behavioural modification for smoking cessation, primary prevention, cancer care, and many more. He calls this "Medical school for the public". He takes stories and engages patients with an active whiteboard illustrating the talk in a multimedia fashion, reinforcing the learning points. Another similar example is University of Toronto's "Healthy Debate" website, which brings easy-to-understand information about the health care system to the public, helping people make informed decisions about their own health. Lastly, behind the scenes, but easy to access, infectious diseases like Influenza and Zika are tracked globally in real time, helping to catch patterns that foresee epidemics, and allowing dissemination of information to local authorities.

3) Promote learning: Faculty and trainees are accessing different tools for reviewing the latest literature and debating evidence. Online journal clubs, like the University of Toronto Respirology and Sleep accredited journal club live tweets their meetings, involving authors who can provide background details to allow critical appraisal of their studies. Blogs like this one disseminate talks to the broader community who share common interests. My favourite - listening to The Rounds Table podcasts hosted by UofT's Healthy Debate, where recent research papers are presented with a critical appraisal and provided a context.

4) Create a global community: Through networking, Dr. Anand shared examples of connections she has made through Twitter with other Cystic Fibrosis physicians and researchers who otherwise would not have met. Barrier-free, open access, instant connection to anyone sharing your clinical, education, or research interest. There is a whole community committed to free and open access medical education on Twitter (#FAOMed). The opportunities are boundless, and imagine the perspectives you have to gain. You can start the connection at a conference. Most now have live tweeting of sessions allowing people to connect.

As the audience engaged in a debate about the potential drawbacks of widespread social media use by trainees, Dr. Anand reminded us of the core principles of responsible use:

1) Maintain professionalism: The rules of engagement are "Don't lie, don't pry, don't cheat, can't delete, don't steal, don't reveal." And avoid all patient-identifying data. Be aware of your regulatory body policies at the local, provincial/state, national level. They share common principles, but some will have unique rules.

2) Own your "digital shadow": Given it's ubiquity, you are bound to find your name somewhere on the internet if you search, and it may not be as you intended. Don't let others speak for you. Set your own stage and be clear in how you want yourself represented to protect your professional identity.

My colleagues took to Twitter to continue a thought-provoking dialogue over the weekend after this talk. While Twitter can be used to disseminate and translate knowledge among health care professionals and patients, how do we ensure the integrity of information, how does this affect research Impact Factors, and what does this mean for print medical journals? One thing is for sure, sharp critical appraisal skills are needed now more than ever.

I admit, I had begun my conversion before this talk, but Dr. Anand solidified my commitment to using social media in medical education. You can follow us on twitter @CEEPAoM. But I remain weary of the potential for addiction and it's effect on mental health. First, if you love information, social media is never-ending. Set your limits. There is an app for purchase that will allow you to access your account for limited hours, similar in concept to parental controls (remember that bag of Doritos - impossible to have just one). Second, there are malicious trolls out there. If you engage in controversial topics, for example tobacco control, be prepared for nasty followers. Block and report them for your own mental health.

Resources:

DocMikeEvans Whiteboard talks @docmikeevans

Healthy Debate hosted by The Rounds Table @roundstable

Evidence-based medicine in the era of social media: Scholarly engagement through participation and online interaction

Twitter's Role in Scientific Publication and Communication INFOGRAPHIC

Melvin, L and Chan, T. Using Twitter in clinical Education and Practice

Ontario Medical Association Social Media Primer

College of Physicians and Surgeons of Ontario Position on Social Media - Appropriate Use By Physicians

Budd L, Fiddler L, Anand, A. Gaining Competence Through Social Media. CMAJ. 2016;DOI:10.1503/cmaj.160255

Bio – Anju Anand, MD

 Dr. Anju Anand is a Staff Respirologist and Sleep Medicine specialist at St. Michaels Hospital in Toronto and Assistant Professor at the University of Toronto. She is also the Education Site Director for Respirology at St. Michaels Hospital. She completed her medical and Respirology training at the University of Toronto and two subsequent fellowships in cystic fibrosis and sleep medicine. Her academic interests revolve around using technology to enhance education and she has been involved in moderating and creating numerous websites for patient education (eg torontoadultcf.com), blogs, e-modules for trainees and for the inception of @respandsleepjc (#rsjc)- an online Royal College Accredited Twitter-based journal club. Her upcoming research involves using Twitter as a tool for educating patients with Cystic Fibrosis online. 

The Infectious Nature of Classical Music

Dr. Dan Petrescu, Division of General Internal Medicine, University Health Network

January 10, 2017

Posted by Nadine Abdullah, MD, MEd, FRCPC

The Scene of the Death of Mimi, from Puccini’s opera “La Bohème”
(Photo credit AllPosters.com)

This week, Dr. Dan Petrescu dimmed the stage lights to take us on a beautiful journey through opera and infectious diseases. Two seemingly divergent topics paired naturally as he expertly guided us through Four Acts – a metaphor for the theme. The beautiful aesthetic of watching and listening to operatic clips in a darkened hospital auditorium in the middle of our busy clinical work day and high-stakes meetings slowed us down, and allowed us pause to listen, breathe, alert our calming senses, and quiet our activating fight-or-flight reflexes. A stark departure from the typical noon medicine rounds on infectious diseases.

To begin, Dr. Petrescu introduced us to the influence of magical thinking in understanding illness. We saw how delirium and febrile hallucinations preceding the death of a child were believed, at the time, to be an assault afflicted by a supernatural being, depicted in Schubert's Opus 1, a musical rendition of Johann Wolfgang von Goethe's poem Erlkönig.

From delirium, we moved on to syphilis and tuberculosis. Mental illness has long been portrayed in music and art, but who would have thought to look for infectious diseases? Learning about the historical context of opera story-telling to understand the societal perceptions of illness in various eras gave us deeper understanding into how communities have stigmatized disease throughout history, such as TB and syphilis. Violetta in Verdi's La Traviata was portrayed glamorously as a thin, pale, diaphoretic, debutante consumed by tuberculosis and sensuous desire, at centre stage surrounded by admirers, on the verge of nuptials. In contrast, we felt the squalor and isolation of Mimi in Puccini’s La Bohème amidst the poverty of her bohemian, disenfranchised and forgotten artists, taking her last breath. The critical event that shaped the latter portrayal was the scientific influence of bacteriology, and the discovery of Mycobacterium tuberculosis as the infectious agent causing consumption, and the airborne means of transmission leading to a shift from admiration, toward isolation and stigma. On a simplistic level, we can use this to illustrate where infection control and isolation practices in public health were born. But on a deeper level, can we use this study in contrast to better understand our community of patients and see illness through their eyes, and see what it means to them? Where the stigma comes from and why they may not align with our proposed treatments?

Reminiscent of how close reading of literary passages is taught in narrative medicine to heighten the listening, observation, and critical thinking skills of healthcare professionals, the study of opera can be seen as another form of close reading. Ranging from discussing music and composer history, to uncovering illness perceptions and biases, to the concrete analysis of key transitions, instrumental voice and themes to indicate mood and meaning, the opportunities to make opera relevant to medicine are immense. And just as one need not be an English major to incorporate narrative medicine into practice, musical training is not a requirement for one's medical practice to benefit from the study of music and opera. It is so commonplace that many medical humanities courses and programmes have emerged throughout North America, combining the study of arts and humanities with medicine. Our very own Drs. Linda and Michael Hutcheon, from the University of Toronto Departments of English and Medicine were early leaders, lecturing internationally on opera and medicine.  It is no wonder that many of us in the audience were classically trained musicians, and why the majority of medical school applications that I read have Royal Conservatory of Music Certification alongside the competitive GPA and volunteer hours.

Infectious disease as portrayed in the arts may now be more obvious to me, but what about other illnesses, like cancer? Verdi's portrayal of tuberculosis resembles that of Susan Sontag's description in Illness as Metaphor, whereas in her historical review, cancer was abhorred, despised, and people were considered to be stricken by dread and shunned. Is this stigma what persists in some communities today, the ones from which emerge the protests: "Don't tell mom she has cancer?" As though receiving the diagnosis would lead to her death, independent from the disease process itself.

The audience was engaged again this week, stimulated, and the inevitable question was indeed answered in closing the talk: Why does paying attention to opera matter in medicine? Opera is a classic, overly indulgent and melodramatic characterization of all that is the best and the worst of human nature and relationships. It is a rich backdrop for delving deeply into people's motivations and choices, a study into human psychology. In health care, one of the professions most reliant on understanding human nature, this deeper understanding of opera can engender empathy, and strengthen our doctor-patient relationships. Dr. Petrescu left us with some of his wisdom. Humans have long sought to understand life and death, illness and misery, and have found meaning and expression through the arts and music. Opera is a rich genre that heightens our senses to the knowledge of the time. The doctor-patient human relationship suffers if we don't step back and listen.

Resources:

Sontag, S. Illness as Metaphor. Vintage Books, 1979

Hutcheon, L and Hutcheon, M. Opera: Desire, Disease, Death. U of Nebraska Press, 1996

A complete medical education includes the arts and humanities

Opera and Medicine Bodily Charm: Living Opera

Physicians in opera - reflection of medical history and public perception

Bio – Dan Petrescu, MD

Dan Petrescu is a graduate of the Internal Medicine and Infectious Diseases training programmes at the University of Toronto. He currently practices both Internal Medicine and Infectious Diseases at Markham Stouffville Hospital and is a Clinical Assistant in the Division of General Internal Medicine at Toronto Western Hospital, attending on the CTU. He takes a special interest in the interaction between the humanities and medicine and has given presentations across the GTA on topics ranging from interesting clinical cases, to classical music as it relates to Infectious Diseases, to the history of vaccines and anti-vaccination movements.

Art of Medicine, Unplugged

Dr. Robert Fowler, Sunnybrook Health Sciences Centre
October 25, 2016

Posted by Nadine Abdullah, MD, MEd, FRCPC

Unplugged medicine: meaning intimate, bare, without extra accompaniments, where the art of the physical exam supersedes limited technological resources. In his compelling manner, Dr. Fowler walked us through his journey, from First World critical care where the art of medicine often falls off to the reliance on machines and numbers, down unexpected paths.

He first experienced working in an outbreak during SARS in Toronto, and at the time made connections with colleagues who were experiencing similar outbreaks elsewhere. A network of clinical researchers was born that would set the stage for international collaboration as globalization of disease grew. Not long after, he received calls from colleagues in other countries to help study their outbreaks; H1N1 in Mexico, MERS-CoV in Saudi Arabia. He established himself as a leader in researching and managing outbreaks, and was sought out for his knowledge. This led to a sabbatical at the World Health Organization (WHO) in Geneva where his task was to review lessons learned from these past outbreaks, and to establish international standard protocols for future outbreaks. He employed the principles of clinical epidemiology to define acute respiratory illness outbreak terminology to improve the reporting of disease, and enhance global collaboration.

During his term, word came of a potential Ebola outbreak in West Africa, and he naturally traveled there with his colleague to see firsthand what was emerging. They found themselves immersed in providing clinical care and managing the outbreak. He described the makeshift setup of a hospital, transfer of sick health care staff, patients and rudimentary supplies from one hospital to this new centralized "facility" to provide ongoing care to the population. In the course of observing the evolution of this illness in individual patients, Dr. Fowler and his colleague noted the impact of dehydration on mortality, and began to institute aggressive IV hydration protocols, with point of care blood testing, oxygenation, and management of target organ damage. Despite limited resources, they began to collect formal data, and through careful documentation and analysis, demonstrated that they could see a 50% reduction in mortality with basic supportive medical care.  The unprecedented high mortality previously documented in Ebola was not simply the result of an inevitably fatal virulent disease, but due in large part to the consequent treatable dehydration, resultant metabolic derangement, shock and organ failure.

Early publication of their data in the New England Journal of Medicine led to widespread understanding of the disease and its management, and put Ebola on the radar of governments and agencies allowing them to recognize need and mobilize resources, eventually halting the outbreak.

Dr. Fowler and his colleague's work has set a new standard for live epidemiological research while simultaneously providing emergency medical care in a devastating outbreak. The individual patient and global population impact is measurable; the timeliness incomparable to the vast clinical research we pore over in medical journals. Their work will serve global health immensely when the next outbreak hits.

This talk was not merely a physician's biography and resume of academic achievements. It was a captivating narrative about the blending of science and humanistic medicine. It illustrated the impact of applying the science of clinical epidemiology to global health. When time was up, and groups lingered to talk more, the discussion turned to the practical personal impact and sacrifice, an intimate experience of leading care amidst a frightening health crisis, and returning to the comfort of a First World health care system. As with our last lecture on MAID by Dr. Gary Rodin, this talk exemplified how the Medical Expert role is inseparable from the intrinsic CanMEDS Roles, this time with a particular emphasis on the Collaborator, Leader and Scholar Roles. But it also had several take-home messages for the learners and junior faculty seeking mentorship and role models for career planning. Here are some lessons I took away:

1. Take advantage of the clinical experiences around you; they will prepare you to be a leader in future unexpected roles.
2. Take a sabbatical that will give you an opportunity to be part of a global collaboration. You might find yourself being the right person, in the right place, at the right time.
3. Get out of your comfort zone. It gives you new perspective from where you work.
4. Remember the importance of giving back. We have developed critical skills and knowledge that can impact the health of a broader, more vulnerable population than that we serve daily.

I wondered; do we spend enough time explicitly teaching and modelling these lessons as educators? Were the senior attending physicians present who had formerly taught and supervised Dr. Fowler thinking with pride that they might have contributed in small part to inspiring this passion? Were the students and residents inspired to think how their future careers would unfold?

A month later, the buzz lingers in the air. Inspired by this talk, what stories about their careers will they in turn be talking about in twenty years?

Bio – Rob Fowler, MD

Dr. Fowler is a General Internist and Critical Care Physician at Sunnybrook Health Sciences Centre, Adjunct Scientist at the Institute for Clinical and Evaluative Sciences (ICES), Associate Director of the Clinical Epidemiology and Health Care Research graduate program of the Institute of Health Policy, Management and Evaluation at the University of Toronto, and a senior Scientist at Sunnybrook Research Institute. He was a WHO consultant during the 2014 Ebola outbreak in West Africa. He has an active research program focused on clinical outcomes of critically ill patients, holds a number of peer-reviewed grants, and has published widely.  More recently, he was appointed to the Order of Ontario.

Resources

NEJM paper: Clinical Presentation of Patients with Ebola Virus Disease in Conakry, Guinea

Fighting Ebola from day one

WHO Ebola Diaries