A Kinder, Gentler Medical Curriculum ...

Hi everyone!

At the end of the month, one of my dear friends will retire from his position as an anesthesiologist and medical educator at Queens University School of Medicine. A warm, compassionate and highly skilled clinician, he has made important contributions to his field by promoting and modelling teaching excellence, developing a resident logbook, and designing and implementing professionalism training for medical students.

Over the years, Ted and I have had many conversations about how to reduce pressure and create a safe learning environment in medical schools, believing that we cannot foster civil, humane, compassionate practitioners in education systems that overwhelm, disrespect, and shame their students. While many educators are beginning to understand the importance of systems that promote student mental health and compassion fatigue resilience, there are still many places where lip service is paid to such notions while educators continue to transmit less-than-helpful values through the "hidden curriculum" of unkind teacher-student interactions and inhuman expectations.

This week, as Ted prepared for retirement, we had another chat about medical education, this time spurred by a new study by Dr Stuart Slavin, MD, MEd, associate dean for medical curriculum at St Louis University, a Jesuit institution in the US.

The paper, published in the April edition of Academic Medicine, looks at the well-being of first and second year medical students before and after changes to SLU's medical school curriculum, changes designed to prevent depression, stress and anxiety. (There is strong evidence that the seeds of these mental health problems are planted in medical school.) Student mental health was measured in 5 classes of 175-178 students - two before the changes and three after - at the medical school orientation, the end of year one and the end of year two.

Slavin says that the study showed a dramatic improvement in the mental health of the students. Depression rates in first year students went from 27% to 11% and anxiety dropped from 55% to 31%. At the same time, test scores increased, showing improved student performance. Slavin said, "Our students know more, and will be in a better situation, emotionally, to care for our patients."

In planning the study, SLU administrators asked students why they felt anxious and depressed and then designed and implemented curricular changes that would directly address the identified stressors. Without sacrificing critical educational components, SLU changed the curriculum to remove unnecessary stressors, (a far cry to the traditional wisdom of seeing stress as an inevitable part of the path to becoming a doctor), and added a required class that teaches strategies for stress reduction.

Students were taught to better manage energy by taking breaks, sleeping, eating properly and exercising; being mindful or paying close attention to what's happening in the present moment; reframing their perspective to be more realistic; recognizing negativity; controlling their reactions to situations; and cultivating a positive and optimistic outlook that ultimately leads to more happiness and personal satisfaction.

In reporting his findings, Slavin pointed out that it is important to the health care system to address depression and stress among physicians.  "Physician depression and burnout are significant problems and may rightly be viewed as a substantial public health problem, particularly given the evidence of the negative impact that mental health can have on clinical care by reducing physician empathy and increasing rates of medical error."

As we talked about this timely paper, Ted and I agreed that it was sad that such a study needed to be undertaken in the first instance but that it was hopeful and encouraging to see that long-needed changes are finally being made as he comes to the end of his teaching career. We spoke about congruence between course content and the behaviours modelled by educators and how integrity between the two makes for a mentally healthy learning environment. We also shared the hope that this sort of congruence will continue to grow as other programs modify their curriculae.

Before leaving you today, I'd like to take a moment to say congratulations, great job(!) and every good wish for a happy and healthy retirement to my friend, Ted Ashbury. Thank you for all you've done for so many years to try to make medicine a kinder and gentler profession.


 

When Your Family Physician Retires...

I went to my family doctor for my biannual physical a few weeks ago and was surprised and just a little shaken to learn that he will be retiring from the practice component of his work this coming September. I had been expecting to hear this news sooner or later but the reality felt worse than the anticipation.

I felt a little as though I was a four-legged stool that had had one leg kicked out. I have known our physician since he was an intern at the teaching hospital in which I worked in the 70's and, over the years of my husband's life with and death from cardiomyopathy, we spoke by phone several times a week and he visited us at home for the three years that Derrick was confined to bed. Over tea and cookies after he'd examined his patient, we came to know him better and liked him all the more. He visited us in hospital during the last week of Derrick's life and both called to check on me after Derrick's death and attended his funeral. He has walked an intense portion of life's journey with us and I will miss him and his kind, steady, support.

I don't think that people generally reflect deeply upon the importance of their relationships with family physicians until they or someone they love is really ill or until those physicians are leaving or have already left. We certainly don't do that as a society, a fact demonstrated by the absence of research into the emotional impact of physician retirement on seriously and/or chronically ill patients and their care partners. And yet, that impact can be great, even destabilizing in some cases.

As with any attachment, particularly a dependent one, the breaking of the physician-patient-family care partner relationship is a loss that evokes grief. In the case of patients and care partners already experiencing chronic sorrow and reduced social support, that grief can feel overwhelming. Even relatively short physician absences can evoke sadness, anger, anxiety and distress.

I remember when our physician played a game of hockey and badly injured his neck, requiring surgery and time off work for most of the last six months of Derrick's life. It was an enormous loss and source of concern for us - worry for our physician, himself; fear about loss of continuity of care and of all the facts rattling around in his head that I might or might not be able to remember on a given day; loss of his relatively easy availability, based on his belief that home palliative care was impossible without physician accessibility and home visits; and his willingness to entertain "outside the box" solutions for Derrick's longterm pain. His absence brought into sharp relief all the qualities with which he'd graced our lives over the years.

I think it is important that we make space to grieve the loss of such a significant relationship whenever a physician retires, is absent for a long period, or when a patient dies and the degree of contact with the care partner changes - space for the grief of physician, patient, and family care partner alike.

It matters that we give each other time to acknowledge the alteration in the previous pattern of life, to say goodbye, and to express unfinished business, concerns and gratitude - aside from all the administrative details. We need a chance to say what the relationship has meant to us. At it's best, the physician-patient-family care partner relationship is one of mutual care, compassion, learning and partnership - and, thus, one deserving of its grief.

So, as it draws to a close, I would like to take the opportunity to publicly acknowledge and thank Dale Stogryn, a fine man, a fine physician and an excellent medical educator, for a twenty-five year relationship of care, respect, compassion and great medicine. I am glad that you will continue with your work in medical education but those of us in your practice will be the poorer for your absence.