The Limits of Physical Diagnosis

Just a few days ago, I took the streetcar across downtown Toronto, something I don't have the opportunity to do very often. I spend plenty of time on the subway and our commuter train network, but the streetcar isn't part of the route I normally take. Streetcars are used by people to go short distances, usually, and this one was heading through one of the inner city neighbourhoods next to downtown. It was crowded, and as I worked my way back from the front door, past a lot of people with packages and shopping carts, I looked up and saw a hand grasping the pole in front of me. Not unusual in itself, but what caught my eye was the perfect example of clubbing that the hand displayed.



Clubbing is a physical sign that we in Internal Medicine look for, and talk about, a lot but don't see very often. It is a change in the fingernails, and sometimes toenails, that occurs in people with a number of different illnesses, but we most frequently associate it with lung cancer. It remains a curiosity, one of those things that provides an enigmatic glimpse into a person's health, because although we don't really understand why it happens, when we see it, we know with few exceptions that it represents a potentially dangerous problem.

We go to great lengths to teach our trainees about how to determine whether the person in front of them really has clubbing, instead of an unusual shape of their nails. A whole system to diagnose the clubbing itself has arisen, and I have spent countless hours at the bedside of patients, many of whom did not actually have clubbing, explaining to students and residents how to make the distinction.




So this hand in front of me, were I in a teaching hospital, might have served as a great opportunity to teach, and pass on the wisdom of the profession, about physical diagnosis, the art of looking for seemingly small changes as portents of big problems. I might have even asked its owner's permission to give his name to my colleagues, so that they could also bring their students to see the hand, palpate its nail beds for sponginess, look for periungual suffusion, and check for the "diamond sign". As I said, we don't see "classic" (some might say, without mentioning the irony, "beautiful") examples of clubbing that often. So this hand would have been a great opportunity.

But I was on the Dundas streetcar, heading through downtown. No crowd of students around. No one looking at the hand apart from me. Even its owner, who was not my patient, seemed to pay it no mind. As I gazed at it (it was about 10 inches from my face), I noticed that the nails were blackened and chipped, and the rough creases of the hand were dirty. Nicotine stained the thumb and first two fingers, and small, burn-shaped scars were visible on the back. The arm was enclosed in a torn, dirty and old wool sweater, which gave off the unmistakable odour of many days' sweat. The man whose hand attracted me was possibly in his fifties, with long dishevelled grey and black hair, which was very dirty and almost covered his face. His cheeks had a good deal of stubble on them, along with a big purple bruise on his right cheekbone, accompanying a black eye. His other hand held about 5 filthy plastic bags, one of which was filled with empty beer bottles, possibly on their way back to the beer store for return of deposit. The other bags had clothes in them, equally dirty to what he was wearing. This man was ignoring me, but muttering under his breath, apparently to someone who wasn't visible to the rest of us. He shook his head a couple of times and cursed in a louder voice. People started to give him more space, and as the next stop approached, he shuffled toward the rear door and stepped out when we got there.

We pulled away and I kept thinking about his hand. If he had been in the safe and clean setting of my teaching hospital ward or clinic, I could have sat with him, talked about the clubbing and the need to investigate urgently, planned out tests and consultations. I could have spoken to him about addictions and social services, and linked him to a mental health professional. With universal health care and a social safety net, everyone should be able to get the care they need, especially when the stakes are high, with a potentially life threatening illness. And perhaps all that had already happened for this man, and I just happened to see him when he was moving from place to place, taking care of his daily business. But this encounter made me think long and hard about the limits of the physical diagnosis that I like to teach, when barriers exist to care, like mental health problems and addictions, poverty, and violence and lack of access to services. What good could it possibly do to recognize classic clubbing, when there is no possibility to intervene, and when so many other issues crowd the landscape and interfere with the "right approach" to the problem? And as an educator, how do I incorporate these issues into my teaching?

The next time I teach about clubbing, I'm going to have to go beyond the simple steps of ascertaining the diagnosis, and branch into less comfortable territory. What do you do when you meet someone outside of a medical encounter, where you know that they have a physical finding that portends something ominous? How do you prioritize problems like lung cancer, violence and mental health? How do you promote access to subspecialty care amongst marginalized people? These are the ways I have thought of that can help go beyond the limitations of physical diagnosis. But I'll take any suggestions you have.

Portfolio Learning - Themes from AMEE 2011

I attended many, but not all of the portfolio related talks at this meeting. In part, it's my duty to do so, because portfolios are a large part of my day to day responsibility. However, it's always been fascinating to me to see how this technique to promote reflective learning has been adopted in different ways around the world. At previous meetings I've been astounded to see the contrast between some countries, where the results of using portfolios to teach subjects like biochemistry (!) are presented, to others where portfolios are used to promote reflection on the larger issues of training and evolution of one's professional identity. And then there have been the North American programs, which by and large have a much less established use of portfolios within their educational systems.

This year, by contrast, I saw a much greater consistency in the discussion amongst the poster presenters and some of the abstracts, which seemed to be tackling some of the deeper, more fundamental issues in portfolio use in medical education. Here are the themes that I saw (of course, fully coloured by the lens I look through, as the director of a local nascent program).

1. Participating faculty need to be trained to support the goals of the portfolio program. Many presenters mentioned the disconnection between the usual set of teaching skills that many faculty members have developed and use regularly, and those necessary to support reflection or assess it. It is universally the case that portfolio programs require large amounts of faculty resources, both in terms of time and numbers of people. We certainly have found this to be the case in Toronto in our first year. In fact, when starting up a portfolio program, one is really starting two parallel educational tracks: one for students and one for faculty. There should be equal emphasis on training faculty as on educating students. This is very daunting when just setting up a portfolio is such a huge task!

2. Getting students engaged is problematic. A recurrent figure seems to be that 30% at maximum of students seem to participate at the level expected of them. I heard much discussion of how students don't seem to understand how good this is for them. I also heard quite a bit about the numerous factors which work against student engagement with a portfolio program. Of these, the fact that portfolios (especially the ePortfolio for Foundation year 1 in the UK) are assessed summatively (for progression) deserves its own theme below. Otherwise, a lack of coaching and examples, and a disproportionately high effort as perceived by learners relative to their benefit, were key themes. One gets the sense that getting learners to do this is like getting them to take their medicine, or eat their vegetables! We know it's good for them so we press on... I don't pretend to have any special answers to this, but my instinct is that the guidance of a mentor, or tutor with a longer term relationship with the student, may coax them along at first, and then if the light goes on in their heads, students may feel they can get more out of this type of work. But of course, we must pay attention to the other side of the ratio - reflection, when well done, is NOT easy, and growth is a struggle. Given the fully stuffed schedule that our learners must maintain, we must pay attention to whether our reflective assignments are too demanding in the overall learning context.

3. The a-word (assessment). The catch-22 came up again: if portfolios aren't assessed, they aren't done, since students don't want to do all this work and have no one look at it. On the other hand, many students resent having their private reflections assessed, and fear the consequences of being honest in their reflections since their faculty will see them. Some presenters showed data that students are happy enough to reflect, verbally and in person, but don't see the point or the need to create something written. The writing part seems like a make work project, which has little to gain for the student, apart from leading to... an assessment.

There are several important threads in this. If assessment is to be valid for the learner and for the program, it must be clear what is being assessed, and there must be a clear reason why this must be assessed. In the case of portfolios, simply asking students to compile their evidence of learning and reflect on it may not meet this standard, if the students have not experienced the benefits of rigorous reflection, and accompanying feedback. The "why" of it all may be really unclear to them. Likewise, the "what" of the assessment, that is the target of the assessment, must be made crystal clear by the program. In our case, we are specifically targeting the development of reflective capacity in relation to 6 of the 7 CanMEDS roles. We are doing this because we assert that developing reflective capacity as a practitioner is a crucial step, and that we believe that students should be able to indicate what they think a given incident means to them. This is a fundamental analytic skill, that is as essential to their professional career as a good history and physical examination. That's why we assess it.

The other key part of this is the idea that reflections may not have to be written. This is certainly true, as John Sandars showed at the previous AMEE meeting in Glasgow with his digital storytelling workshop. However, I argue that a reflection needs to be 'created', whether that creation is in textual or another form. A simple discussion is a good start, but to critically examine one's biases, assumptions, and automatic behaviors requires concentrated effort, and when thoughts must be committed to page (or .mp3, .jpg, .mpg, powerpoint etc) one is more likely to make the effort. We have found, in general, that students go quite a bit further in written portfolio sections than they do in conversation. So, because we value the ability to reflect on personal experiences, and have created an assessment for it, we insist that students create reflections in the same way that they have to create a written up history and physical examination for assessment of their clinical skills.

I hope you'll comment on the above. What do you think of these issues in portfolio and reflective learning?

Back home at AMEE in Vienna

Well, a 7 hour flight with a whole bunch of irritable children, a quick change of clothes and I arrived at AMEE2011 on Monday August 29.

This meeting is perhaps the pre-eminent international forum for sharing with and learning from medical education colleagues from around the world.  A welcoming environment is promoted and it's a great place to showcase your work and hear what others are doing in your field.  This meeting once again was true to form! 

Check the link to the picture gallery for a few highlights of AMEE.  I'll highlight a few key themes in subsequent posts over the next few days.

Reflection, Narrative, and Professionalism

This week, the University of Toronto Faculty of Medicine had a major event which brought together many people from all parts of our education world, and beyond, to attend a day and a half devoted to "Building a Culture of Professionalism". It was organized by a group of senior leaders responsible for Ethics and Professionalism, experienced faculty developers, and leading researchers from our institution who focus on Professionalism in medical education and medical practice.

To describe the experience as "mind-blowing" is to put it mildly. As a medical faculty, we generally describe ourselves like many others - with a strong research background (after all, Toronto is where both insulin and heparin were discovered, and we're still not over it), and where the clinical environment is dominated by the processes of care, which we pride ourselves on delivering in an efficient and effective manner. Yes, we deliver education, and we feel we deliver it well, very much a product of our hard work, ingenious mechanisms, and mobilized resources. And from this workforce of dedicated, very hard-working and hard-pressed individuals, about 75 came to attend a workshop where we listened to stories.

What? Well, this was an immersion into narrative, for which the overt agenda was to talk about professionalism. However, at the end, I believe the real agenda was a bit different - to get us to listen, appreciate, support, and collaborate, without necessarily "teaching" us anything. All of our activities were based around hearing or telling stories, mostly from each other, but also from our facilitators. This is what made it mindblowing, because we habitual busyworkers possibly walked away not sure of what had been produced in this time together. Where was the blueprint for changing the faculty's approach to professionalism?

We spent this time in the company of Dr. Tom Inui, and Dr. Rich Frankel, from Indiana University, who are both renowned for many things, but in this context spent time telling stories of how IU's school of medicine had a culture problem, extending from the undergraduate students all the way through faculty to the dean, and back. People just weren't happy to be working or studying there, despite many markers of success in the different parts of the institution. They began a process, without knowing what would happen, of getting faculty and others to tell stories of success. While this may seem like an odd way to open up a discussion aimed at helping problem areas, it has a name, Appreciative Inquiry, and a literature from Organizational Development which backs up its utility. From their account, this process took hold very quickly, and soon they had hundreds of faculty engaged in finding out all the "good stuff" that was going on, hearing about it, and spreading the news. This in turn led to faculty and others learning to share stories about other things going on, like personal illness, times of crisis, and things that they observed which they had feelings about. This brought a new culture of reflection, narration, and openness to the faculty, and by their account, the place has been transformed into one that attracts people instead of driving them away.

All well and good, but what did this do for us? Tom and Rich had a very sneaky parallel process going on. When we talked about a poem that was on the screen, many people contributed to a 45 minute open discussion, where widely divergent views were expressed, about what the poem was about, whether it was any good, or whether its message was valid. The tone of the discussion was pretty collegial, yet it was clear that people had strong views. All of them were health professionals who could have spent the time wishing they were taking care of other work. And when we were told to discuss "stepping stones" in our development, we all found a personal story to share, and did so to each other's full attention. So now I know something about a senior pediatrician, a departmental leader in faculty development, and an orthopedic surgeon that I never would otherwise have known. But what I really learned was what it felt like to open myself to colleagues, and to be open to them, on a personal level that we don't usually get to.

So what - can't we do this at a cocktail party? Yes, except that we don't have them, maybe because we might confuse them with a disease. (Or maybe I've just never been invited...) And we don't really get to hear our colleagues showing their deep and authentic selves, even if we did have a cocktail party (not that I don't want to be invited next time). Yet for people who do such important work, and commit so much of themselves to it, isn't it amazing how good it feels to learn about each other's successes, and what lies beneath the professional, competent exterior?

So we spent time over this day and a half learning bits and pieces about each other, but what we took away was the process. Telling and listening; "participating in a narrative" - if you like, an extended narrative about all the faculty. One could call this experiential learning, except that the experiences weren't brought back explicitly for reflection or discussion. It is up to each of us to take something important from this. My personal learning point is how transformative it can be to participate in this, and I want to do more.

I found that this was not, in the end, a session about professionalism per se. It was an immersion in narrative, or rather our narratives, and showed us implicitly how easily we could step out of our usual roles and relationships and do this. And by doing this, we open up the possibility of discussing professional behaviour, celebrating what is done well, and creating a new narrative for what we want to change. This day and a half was a spent in a process, and that process is where the learning occurred. The next part of the process will be to keep this going. Have we each been sufficiently transformed?

Thanks to Minneapolis - Had a great meeting at SGIM 2010!

This was my 9th meeting of the Society of General Internal Medicine, which is the national academic organization for General Internal Medicine in the US, and this meeting is the largest meeting for this medical specialty in the world.

Here are the American cities I've been to because of SGIM, all of them for the first time. This is one way to make sure I get to know many sides of our neighbour to the South.

1999 - San Francisco
2001 - San Diego
2002 - Atlanta
2004 - Chicago
2005 - New Orleans
2007 - Los Angeles
2008 - Pittsburgh
2009 - Miami
2010 - Minneapolis

SGIM has always had a significant Canadian membership, and most meetings have had a strong Canadian contingent, from both the Toronto area and the Western provinces. in fact, there have been 2 meetings held at Canadian sites (Vancouver, 2003 and Toronto, 2006), but I didn't make it to either of them. The first was during the SARS epidemic, and it was all hands on deck in Toronto, so I couldn't travel (nor could I risk taking the virus to the convergence of American General Medicine accidentally). And of course, when it was held in my own city, I could never make the time to go.

This is a pity, because I have consistently found these meetings to be excellent opportunities to learn about the American medical system, with all the frustrations that my colleagues express, as well as all the dedicated, imaginative, and passion-driven work that they do to deliver excellent primary care under the circumstances of their own system. It would have been great to be able to do this when my SGIM friends were on "my" side of the border!

On that note, it was exciting to be present at the first meeting since President Obama's health care reform bill was signed into law. There was a mood of optimism about the future, and Dr. Elliott Fisher gave a great plenary address, urging all present to see the challenges ahead as the "glass half full". This replaced the frustration and resignation that I have observed at previous meetings. Could it be that in my practice lifetime, the United States' health care system will actually serve all its citizens, in a just, equitable and comprehensive way? If they ever get the whole country's citizenry looked after the way the VA takes care of their vets, the Canadian system will have a lot to envy.

This year's meeting fulfilled my usual expectation of having great interactions with exceptional people, learning a great deal, and leaving with my head bursting with ideas. For the first time I took on leadership responsibilities for the meeting, as Chair for the Web-based Innovations in Medical Education category of submissions, and delivered 2 types of educational activities: One being a precourse, and the other being part of the annual Update in Medical Education. These deserve separate blog entries of their own.

And, I met some great new contacts who will be very helpful to me in the coming year, when I am responsible for the nascent Portfolio program of the undergraduate medical program at the University of Toronto. These new contacts, with whom I have significant overlap in interests (given that we kept running into each other at the same workshops!) were people that I automatically connected with on both a personal and professional level. I am VERY excited about the possibilities that these interactions will bring.

And the city of Minneapolis was a very pleasant surprise. So I'm making a blog entry for it as well.

Next year's meeting will be in Phoenix, Arizona, and I will again be on the Program committee. I'm looking forward to continuing to build my career in close association with SGIM!

Welcome - We'll get started soon!