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QMR

QUEENâ€™S MEDICAL REVIEW

CHRONICLES

OF MEDICINE

Table of Contents ISSUE 11.1 CHRONICLES OF MEDICINE Letter from the Editors Essays & Articles

Creatives & Reviews Borders Ashna Asim (Meds ‘20)

Unethical Medical Experimentation: The Good, The Bad, and The Ugly Andrew Belyea (Meds ‘21)

The Story of the Calculator Sachin Pasricha (Meds ‘20)

Tales of a First Year Nothing Anonymous

Advice For My Mother, 28 Years Ago Ramita Verma (Meds ‘20)

Volunteerism & Clinical Exposure Mohammed Mohiuddin (Meds ‘21)

Book of the Issue - Dying: A Memoir Maggie Hulbert (Meds ‘20)

Girl Talk! Roya Abdmoulaie (Meds ‘20)

How I Learned to Heal Palika Kohli (Meds ‘21)

Therapeutic Benefits of Journaling in Medicine Alisha Kapur (Meds ‘21)

2017 Diary Series Anonymous

Unspoken Sharon Yeung (Meds ‘21)

Interviews

A Person, in Context Scott Wakeham (Meds ‘20)

Interview with Dr Max Montalvo: Art in Medicine Sara Brade (Meds ‘21)

Interview with Dr Sanfilippo: Shubham Sharma (Meds ‘21)

How Did We End Up Here? A Short Chronicle of Health & Illness Bryan Franco (Meds ‘21)

Production Team QMR EDITORS-IN-CHIEF Edrea Khong & Chantal Valiquette

WRITERS & MANAGING EDITORS EDITORS

Roya Abdmoulaie Ashna Asim Andrew Belyea Sara Brade Bryan Franco Maggie Hulbert Alisha Kapur Palika Kohli Mohammed Mohiuddin Sachin Pasricha Shubham Sharma Ramita Verma Scott Wakeham Sharon Yeung

Shannon Tang Ali Dergham

LAYOUT

Shakira Brathwaite Natasha Tang

ILLUSTRATION Hassan Hazari Martina Heinelt

The views and opinions expressed are of the original authors and are not necessarily representative of the views of Queen’s Medical Review, the School of Medicine or Queen’s University Please address all correspondence to: Queen’s Medical Review c/o Undergraduate Medical Oﬃce 80 Barrie Street Kingston, ON K7L 3J7 Email: queensmedreview@gmail.com

Letter from the Editors Dear Readers, On behalf of the Queen’s Medical Review staff and contributors, it is with great pleasure that we present issue 11.1: Chronicles of Medicine. The importance of stories, particularly patients’ stories, is impressed upon us from the very beginning of our medical training. “The history solves the mystery” is a pearl of wisdom shared by Dr. Basia Farnell in second year clinical skills. Much of our role as communicators, especially with patients, consists of simply listening. However, we believe these principles extend beyond the scope of clinical practice and encounters. In addition to learning from our patients’ stories, we must learn from our peers, our history, and our social and cultural strata, both in the context of medicine and outside of it. Medical students, physicians, and patients are all people. They are people with diverse backgrounds, innumerable stories, and unique experiences and opinions, all of which impact our healthcare. For these reasons, we are thrilled to devote our first issue as editors-in-chief to examining the importance of chronicling the many stories our chosen profession. We hope this issue allows you to further explore the many narratives of medicine. This issue of the Queen’s Medical Review opens with investigations by Andrew Belyea (2021) into stories of unethical experimentation, analysing times when medical research placed science before humanity. This is followed by reflections on the first two months of what is sure to be a challenging but rewarding journey through medical school. Sara Brade (2021) interviews emergency medicine physician and filmmaker Dr. Max Montalvo on the importance of storytelling in medicine, and Ashna Asim (2020) reminds us that we all have our stories to tell. A tale of increased reliance on technology from Sachin Pasricha (2020) is a gentle reminder that we must maintain some distance to keep our brains sharp. In Girl Talk!, Roya Abdmoulaie (2020) compiles anecdotes from the QMed student body, shedding light on situations often kept a secret within hospital walls. Insight and tips on journaling as a complement to medical studies are given by Alisha Kapur (2021). Ramita Verma (2020) shares a powerful and deeply personal piece regarding advice for her mother. Maggie Hulbert (2020) reviews a memoir which explores assisted suicide, while Sharon Yeung (2021) shares a personal story that impacted her approach to medicine. Our issue continues with Scott Wakeham (2020) detailing his experiences in learning about addiction at the Hazelden Betty Ford Centre in the summer. Through a freeform poem, Palika Kohli (2021) reveals the impact of music on her life, while Bryan Franco (2021) gives a brief account of the evolution of medicine. A student struggles to find their place among the sea of new faces in QMed, then Mohammed Mohiuddin (2021) shares his thoughts on the rise of voluntourism. This issue concludes with an interview by Shubham Sharma (2021) with Associate Dean Dr. Anthony Sanfilippo about his well-loved blog. As always, this issue of the Queen’s Medical Review is a result of the hard work and devoted efforts of our staff. This would not have been possible without our managing editors Ali Dergham (2021) and Shannon Tang (2021), graphic designers Hassan Hazari (2020) and Martina Heinelt (2021), layout designers Natasha Tang (2021) and Shakira Brathwaite (2021), and our entire writing and editing team. We would like to extend our sincerest gratitude to our fantastic team for their incredible contributions to this issue. Although certainly not without its bumps along the road, we are incredibly proud of what we have accomplished together. Without our team and you, our dedicated readers, the QMR would not be possible. Thank you, and we hope you enjoy 11.1: Chronicles of Medicine.

Edrea Khong & Chantal Valiquette

UNETHICAL MEDICAL T H E G O O D, T H E B A D, A N D T H E U G LY Andrew Belyea, Meds ‘21 “Doctors?” said Ron, looking startled. “Those Muggle nutters that cut people up?” –J.K. Rowling, Harry Potter and the Order of the Phoenix Medical experimentation is a unique field because a small discovery can change millions of lives for the better. In principle, we want the fastest results as quickly as possible. However, in pursuit of this goal we can demonstrate a tremendous capacity to ignore our empathetic selves. Far too often the concerns and desires of the human

test subjects are forgotten or ignored. These are three such stories. Statesville Penitentiary Malaria Experiments In the 1940’s, the United States Army, the State Department, and physicians from the University of Chicago’s Department of Medicine conducted a series of malaria experiments on prisoners at the Statesville Penitentiary in Joliet, Illinois. The American interest in malaria treatment had risen since the start of WWII because troops were deployed throughout the malar-

ia-endemic Pacific. With high rates of infection in that region, the military estimated millions of man-hours had been lost to malaria illness. At the time, malaria was treated with quinine; however, Japan’s control of the South China Sea cut off America’s access to the anti-malaria drug. America’s desperation for an alternative treatment led to rapid experimentation on humans. Spearheading the charge was Dr. Alf Alving, a University of Chicago nephrologist who led the research team alongside two other doctors. The primary purpose of the experiment was to test the novel antimalarial drug primaquine, a variant of quinine. The research team bred mosquitoes and infected them with the Plasmodium vivax virus, a less virulent form of the deadly Plasmodium falciparum virus that causes malaria. The researchers facilitated a constant number of mosquito bites, following which they dissected the mosquitoes to determine the viral intensity. Once the prisoners had contracted malaria, they were treated with analogues of pamaquine, an existing malaria treatment unfavoured because of its toxic side effects. A wide range of doses were tested, including some known to be toxic, to determine the maximum tolerated dose. In one case, a prisoner subject died several days after injection with a fatally high dose. The prison system offered a superb environment for scientific testing as confounding variables were largely limited by the maximum-security prison’s strict rules. Inclusion criteria for participation comprised of

Essay

EXPERIMENTATION being a Caucasian male, which was the primary demographic at Statesville Penitentiary. The majority of inmates were serving long sentences, which supported the collection of follow up data. Ethical arguments have since arisen about the treatment of prisoners and the process of randomized control trials. At the time of the prison experiments, there was minimal resistance to prisoner medical experimentation given America’s focus on winning the war. Once the war had concluded, the vice president of the University of Chicago, Andrew Ivy, wrote the Green Report which justified the University’s actions during the malaria experiments. Speaking at the 1946 Nuremburg Trials, Ivy justified that experimentation on inmates was ethical. The rationale for this argument was that the outcomes of the Nuremburg Trials were directed at war criminals and not at American researchers. This viewpoint was further used as a point of defense by the Nazis who stated they were not the only ones conducting immoral research.

cancer killed her a few months later. Unbeknownst to her, cells from her cervix had been removed without her consent, were cultured in a lab, and have since been used in thousands of research projects.

"Knowing what we know now, if we could go back in time to ask for her consent and she did not provide it, would we do anything differently?"

Concerns about consent, coercion, and adherence to the randomized control trial’s structure continue to be discussed about this case, demonstrating its importance in the history of human experimentation.

The ethical dilemma here is clear: Mrs. Lacks’ cells were taken without her permission. What is less clear is the following: knowing what we know now, if we could go back in time to ask for her consent and she did not provide it, would we do anything differently? Would we still take her cells given their vital importance to medicine?

Henrietta Lacks and the famous HeLa cells Henrietta Lacks was an African-American woman born in Roanoke, Virginia on August 1, 1920. Mrs. Lacks lived a largely uneventful life working as a tobacco farmer, although her life was dramatically changed with a diagnosis of cervical cancer in 1951; the

The cervical cancer cells were removed from Mrs. Lacks by Dr. George Otto Gey, a cell biologist at Johns Hopkins Hospital. In 1955, four years after Mrs. Lacks’ death, Dr. Gey noticed the cells’ unusual durability, surviving significantly longer than previously attempted cell lines. Following this encouraging finding, he isolated and

grew the cells. The cell line became known as ‘HeLa cells’ after Henrietta Lacks, and they have since contributed enormously to medical research. Since their use began in 1955, over 10,000 medical patents have been registered using HeLa cells. One of the greatest uses of HeLa cells occurred later in 1955 when Jonas Salk used them to develop a polio vaccine. Heralded as one of the greatest medical advancements in the 20th century, the incidence of polio dropped by 85-90% in the United States just two years after the vaccine’s inception. The remarkable success of the vaccine has led to further refinements, creating cheaper and more easily administrable vaccines. In 2016, the WHO reported a mere 37 cases worldwide. It is easy to get lost in the medical discoveries sprung from HeLa cells, forgetting about Mrs. Lacks and the cells she unknowingly gifted to the world. Given their participation in this famous medical ethics case, Johns Hopkins Hospital decided to address the issue in a 2010 statement. Importantly, they acknowledged that the laboratory which received her cells in 1951 had a pre-established arrangement to obtain cervical cancer cells from any patient diagnosed at the Hospital. At the time, informed consent was not the standard for tissue/cell donations. This muddies the ethical debate: when the cells were removed this was an accepted medical practice, while in the 21st century it would be illegal. Does the Hospital’s 1951 policy (or lack thereof) on consent make what Dr. Gey did morally right? No, it doesn’t. But he was also a product of his learning and work environments and we cannot forget this.

Essay

We must reflect on our own clinical and research roles and ask ourselves what unethical practices are we unknowingly engaging in and how can we change them? We cannot ignore how future historians will surely reflect on the medical practices of 2017 and scoff at how we too failed to learn from our predecessors. We must make a concentrated effort to reevaluate our viewpoints, biases, and judgements to be better clinicians and scientists. N.B.: For those interested in the life of Henrietta Lacks and/or the topic of medical ethics and informed consent, you are recommended to read the prize-winning book The Immortal Life of Henrietta Lacks (2011) by Rebecca Skloot. India’s Rotavirus Vaccine Discussions of unethical research are certainly not limited to the 20th century. A 2014 study published by Bhandari et al. in the Lancet drew worldwide criticism for its randomized control trial investigating a new rotavirus vaccine in India. Although two readily available oral, live, attenuated vaccines existed (RotaTeq manufactured by Merck and Rotarix by GlaxoSmithKline), they were not financially feasible for India to implement. As such, neither option was subsidized by India’s national immunisation program. Without a rotavirus vaccine, the estimated 11.36 million annual episodes of severe rotavirus gastroenteritis (SRVGE) persisted unabated by vaccination. The study’s goal was to assess a more cost-effective 116E rotavirus vaccine that the researchers had developed as part of the joint Indo-US Vaccine Action Program. The ethical issue that has arisen from the study’s publication regards their control group: rather than maintaining

equipoise by providing the globally accepted standard of care (i.e., one of the existing vaccines), the control group was given a saltwater placebo inoculation. Unsurprisingly, the percentage of SRVGE in the control group was more than double that of the treatment group.

country. For an Indian healthcare system that lacked a rotavirus vaccine, many would argue that ‘something is better than nothing’. The process by which this ‘something’ is researched is critically important though, and the strictest ethical principles must be upheld for all people involved, regardless of nationality.

"We owe it to society to conduct our research in such a way that predicts ethical concerns before they arise"

In all three stories, the golden rule of ‘treating others how you would like to be treated’ has been cast aside. Sometimes these cases bring about vast changes, such as with prisoner experimentation which is now more tightly regulated. Other times, outcry from the research community about the mistreatment of subjects can bring these ethical topics back to the headlines.

This control group is ethically concerning to say the least. Simply put, this study would not have taken place in other countries where the standard of care is higher. Ethics approval for the study was granted in India because it’s national ethics guidelines did not mandate such strict requirements; however, the United States-based Western Institutional Review Board also accepted the study when it should not have. The argument to be made is that the researchers took advantage of the marginalized Indian study participants. This study would not have received approval in a Western country on the basis of unethical human research, so what makes the country of study so important? The key difference that cannot be overlooked is the standard of care in that country. Referencing the global standards is one thing, but it is naïve to think that those standards are feasible for every

No matter the perspective we have on these stories, we owe it to society to conduct our research in such a way that predicts ethical concerns before they arise. To prevent these issues from ever arising in the first place. N.B.: In March 2016, a rotavirus vaccine was introduced in India’s Universal Immunization Program, along with vaccines for polio, measles and rubella, and adult Japanese encephalitis. Sources

1. https://www.biography.com/people/henriet1ta-lacks-21366671 2. Bhandari, Nita, et al. “Efficacy of a Monovalent Human-Bovine (116E) Rotavirus Vaccine in Indian Infants: A Randomised, Double-Blind, Placebo-Controlled Trial.” Lancet (London,England), vol. 383, no. 9935, 2014, pp. 2136-2143. 3. http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)62630-6.pdf 4. https://amhistory.si.edu/polio/timeline/index. htm 5. http://www.who.int/mediacentre/factsheets/ fs114/en/

Essay

TALES OF A FIRST-YEAR NOTHING Anonymous, Meds

For full disclosure and for the sake of honesty, I originally wanted to chronicle the changes in perspective of a physician as they revisit the role of being a patient. This was a terrific idea in my head, but like climbing into a cardboard boat in Lake Ontario, it didn’t execute the way I had imagined it. Blame writer’s block, or the startling realization that I am wholly underqualified to talk about being a medical student, let alone even think about being a doctor. But feel free to ask for my bootleg medical advice – I can promise you, I have two whole months of medical education to back up my opinion. Instead, allow me to share with you my unbelievable metamorphosis over these first few months of medical school. Years ago, I started off on this journey as a bright-eyed and preppy first-year undergrad who was unaware of the weight of the textbooks I would soon bear on my shoulders and the shadow that would loom over my uncertain future as a keen

premed. I gradually built up a fragile cocoon of stress, known to lay folk as “MCAT”, “applications” and “MMI”. But fear not, in the Kingston wind, I’ve broken out of my cocoon, spread the breathtaking blue wings of a beautiful 2021 and finally sprouted my stethoscope. Throughout undergrad, I prided myself on my neat handwriting and meticulous notetaking. You’d have to strain to have difficulty reading my notes. I always thought that the stereotype of doctors with horrible handwriting was nothing more than a joke. But since the very moment I accepted my offer, my writing has begun to deteriorate. Using my new interest in clinical research (thanks, CARL), I’ve enrolled myself in a prospective cohort study examining the effects of sleep deprivation on the handwriting of medical students. I have a slight suspicion that I’m in the exposed arm of the study, so give me a month and maybe I’ll be able to write myself a prescription to fix it. The prognosis can’t be good, my notes have already taken on the characteristic scrawl… I used to go to doctor’s appointments with equal measures of apprehension and anticipation. Who knew what type of germs could be floating around the waiting room? And Dr. Google can only answer so many questions… I’d always put in my symptoms correctly but I’d always get the same diagnosis – I’d be dead before getting out the door. But it was fine because the real doctor would always know what to do, and I’d always make sure to tell my doctor as much as I could remember. Just like how I’d heard it was always important to let your doctor know if you had chest pain. So even if I’d forgotten until then, I’d always tell my doctor about that time my chest hurt three weeks ago, just before they’d get out of the examination room. I thought

it was my due diligence. But the last few weeks of class have taught me so much about medicine, and I’m a much more competent patient. I walk in, ready to present my symptoms and history organized in A SOUL DSCLO TRAAAP, and I FIFE myself before the physician can even open their mouth. And you know what, I don’t even need Dr. Google anymore - I’ve got my fam med schemas ready to go. It’s interesting to look back on all the times I doorknobbed my doctor in the past, but I learned my lesson right away in clinical skills. It’s amazing, really. Now that I think about it, not only can I conduct the interview myself, I can also build my own rapport so the doctor can just sit back and relax. In fact, I even take my own vitals. It’s hard not to when your stethoscope has anastomosed to your neck. Given another term, I could easily do my own bloodwork too. I mean, we’ve already learned about vasculature in anatomy, how hard could it be? Thinking back to my premed days is almost amusing. How little I knew back then! But it almost scares me to say that in a few years, I’ll look back again, afraid of what I now think is possible. I’ve discovered that blossoming into a real, live med student has changed me drastically. I can say confidently that these last few months have been a joyride, but I don’t think I’ve unlocked the full potential of my heavy blue bag or my stethoscope. In fact, now that I think about it, I could fit so much more inside it… After all, you never know when you might need your very own examination table or that extra atlas… It’s a good thing I have a hundred new friends to keep me grounded. That is, only if my backpack doesn’t weigh me down first.

INTERVIEW: ART IN MEDICINE

D R . M A X M O N TA LV O Sara Brade, Meds ‘21

Abraham Verghese, physician-author, contends that, “[Physicians] should be not just ‘doctors for adults’ but also ministers of healing, storytellers, storymakers, and players in the greatest drama of all: the story of our patients’ lives as well as our own.” In this article, I interview Dr. Max Montalvo, an emergency medicine physician and filmmaker, on what it means to be a physician-storyteller. QMR: Please tell us a little bit about yourself, your journey to medicine, and the intersection of filmmaking in all of that. Any favourite film projects you’ve been involved in? MM: I was born and raised in Mexico City, and immigrated to Canada with my family in 1982. Growing up I wanted to become either an astronaut or a medical doctor. When I was a teenager I remember watching a show on television about the physical rigors that astronauts go through during their training. The scene of trainees spinning on a human centrifuge made my decision to pursue medicine easier. From an early age, I was immersed in a rich artistic environment. My mother is a fine arts artist who exposed me to a wide variety of painting styles, music, and native Mesoamerican art and culture. At the age of 10 my parents bought me my first classical guitar after I heard Elvis Presley’s ‘Heartbreak Hotel’ playing over the Mexican airwaves. My interest in film also goes back to my childhood. My father had a super-8 consumer camera which I would frequently play with without film in it; I remember loving the way the world looked through the viewfinder eyepiece and the sound that the camera made. To this day, I still use super-8 film cameras in some of my films. When I completed my residency at Queen’s in emergency medicine, I was craving to do something creative. In 2010 I directed my first feature length film, EL PAYO, a documentary chronicling the tragic story of David Phillips, an obscure and influential guitarist from northern Ontario who spawned a vibrant flamenco culture still thriving across Canada. Underscoring Phillips’ own sublime flamenco sound, EL PAYO featured original music and performances by a number of contemporary stars, including the acclaimed ‘First Lady of

the Guitar’, classical guitarist Liona Boyd, flamenco musicians Jose Valle ‘Chuscales’, Miguel de la Bastide and Paco de Leon, and The Tragically Hip’s guitarist Rob Baker and percussionist Johnny Fay. My friendship and collaboration with Rob Baker and the band led to a series of music videos and a short film which I produced and directed for The Tragically Hip. In 2013, we launched ‘161!’, an online visual poem that explores human perception (www.161factorial.com). Using the 161 images of The Tragically Hip’s music video “Now For Plan A”, the 6-minute piece loops continuously, each time in a new, random order. Earlier this year I was honoured when the video for the single from the band’s latest album, “In A World Possessed By The Human Mind” was awarded the best Rock/Alternative video at the 2017 Much Music Video Awards.

"Developing ‘narrative competence’ can help bridge the gap between the perceptions of patients and caregivers on themes of illness, mortality and emotion." In addition to my work in the music and film industries, I have been developing ideas for the use of film and sound in medical education. In my role as assistant professor and attending physician , I've created a series of short films that have been

Interview

used in the faculty of Emergency Medicine at Queen's University. More recently, I led a workshop on using the short film genre as an innovative method of medical teaching at the International Conference on Residency Education.

cusing on the patient – the person in front of me. How do you think focusing on the narrative and personal story of the patient can benefit medical trainees and their future patients?

QMR: How has your ability to tell stories through film influenced the way you see your patients and practice medicine? What role do you think the narrative plays in the way patients relate to their illnesses and doctors relate to their patients?

MM: The cornerstone of the medical interview is a proper, accurate history. The traditional model of the medical interview has stood the test of time. By working towards mastering techniques of history taking we can aim to start every interaction with a solid base from which the rest of the patient encounter flows. I feel that the basis for proper communication starts with our own observations and listening skills. We often attribute limitations in our ability to extract relevant information from patients under the perception that the patient may be a ‘poor historian’. Focusing on the structure

MM: A few months ago I attended ‘Creating Space’, a symposium on health arts and medical humanities. Dr. Rita Charon, an internist and Ph.D. in English Literature at Columbia University, delivered a profoundly inspiring and affecting presentation on narrative medicine, defined as “medicine practiced with these skills of recognizing, absorbing, interpreting, and being moved by the stories of illness”. Developing “narrative competence” can help to bridge gaps between the perceptions of patients and caregivers on themes of illness, mortality, and emotion. Every patient tells a story. In the emergency department, patients may arrive experiencing chaos or uncertainty to see an unfamiliar face in the attending physician. Gaining trust and establishing a close connection with patients within a short time can be critical for physicians to obtain important and relevant information for quality care. Experienced clinicians can often obtain a richer understanding of the patient by asking certain questions, which at first may not appear centrally relevant. ‘How did you prepare the chicken you ate before your abdominal pain started?’ ‘What were you fishing for when the hook became lodged in your thumb?’ Those aspects of the patient history can help create colorful visual vignettes that help to enrich the clinical encounter as well as the experience of the clinician. QMR: As a new medical student, it is easy to inadvertently make myself the centre of attention in a patient interaction by getting lost in the questions I have to ask instead of fo-

"The patient’s stories will always remain fresh, enriching and unique" of the medical interview can guide physicians in asking the right questions. As clinicians, we can continually improve in our ability to listen and to ask questions which over time can lead to not only refining our own interviewing skills, but to make a stronger connection with our patients. QMR: Any advice for medical trainees? MM: Clinical medicine is a beautiful, meaningful and rewarding career where we are privileged to be in a position of looking after people who see us during vulnerable times in their lives. With time, aspects of any medical specialty, like most other careers and occupations can become routine. But the patient’s stories will always remain fresh, enriching and unique. Thank you, Dr. Montalvo, for sharing your stories with us.

Creative

BORDERS Ashna Asim, Meds ‘20 Wearing my mother’s cardigan feels like playing dress-up again – I’m six years old and searching through her vanity for lipsticks and perfume. The cardigan is heavier than it looks. Somehow, without my knowing, the years have stretched on and I’m starting to borrow my mother’s worries, fears, and anxieties like I borrow her clothes. Soon I’ll see her in strands of my greying hair and I’ll feel her in my arthritic knees. I shouldn’t be so surprised that my mother is now marked onto each crease of my skin. One day, when I slip my arm through the soft material of her blouse, my mother’s hand will appear at the other end. Bony knuckles, skin sagging like a loose shawl draped gently over hard bone: creasing and folding to create indecipherable borders. * My brother wears the eyes of security guards on his back. We’re waiting for the train to take us home; it’s been delayed. As he makes his way over to where I’m sitting, each step my brother takes feels like the creak of a loose floor board. At some point in the past, my brother was shorter than me. I was the one he ran to when he was afraid, fought off playground bullies, and held his hand when we crossed the street. My brother always trailed behind me, like a restless shadow.

Now, he towers over me. There’s light stubble cloaking his baby face. His skin is a few shades darker than mine, making his body more visible. Can’t my brother feel the glares on his back even as he eats his sandwich? My brother gets up to throw away his empty wrapper. His legs make long strides towards the garbage can. The security guard’s eyes are fixed on him. My brother’s footsteps thud inside me like a doorknocker. As we wait for the train, many miles away my parents are waiting to receive us at home. I imagine my mother has prepared a feast for us to celebrate our homecoming, safe and sound. I can hear gunshots. My brother is playing a game on his phone. His brows furrowed in concentration, back and shoulders hunched over. His eyes light up like the screen. He turns the phone towards me so I can see his new high score. * I fetch hand cream for my father. His skin - chapped and cracked around the knuckles from the icy wind. He woke up an hour before I did to shovel snow off the driveway so I can make it to my big interview. The same as it’s always been. Changing my tires, filling up the gas tank, getting my car checked, shovelling the driveway – this is his language. Fetching hand cream and making him a cup of tea – this is my language. There are some things that aren’t said out loud. My parents have crossed many borders so we won’t have to. So we have a place to call home. But some nights, I can hear my mother cry as she prays – forehead pressed against the ground. There’s an ocean between the old world and the new, but not much else. Sometimes, late at night, I sneak into my brother’s room to make sure he’s breathing – like my mother’s always done. I hold on to the hope that if I take on this burden – of making sure his breaths are full and uninterrupted – then my mother will have one less thing to worry about. And I can convince myself that we’re safe.

Creative

THE STORY OF THE CALCULATOR Sachin Pasricha, Meds ‘20 I am buying my morning coffee. $2.80 is the price. After handing a $5 bill to the cashier, I scavenge up a quarter and nickel to give to the cashier as well. He looks at me perplexed and proceeds to pull out a calculator. He types in “$5 + $0.30$2.80”. I thank him for the coffee after taking my change and proceed with the day. But the incident does not leave me with without concern. Needless to say, the progress of technology is present everywhere around us. From the Starbucks app to MedTech to the simulation equipment used in residency programs, there is no escaping it. The possibilities created by most technological applications are remarkable. The imminent threat technology poses, however, is the decline of much needed skills, notably mental math.What is (10 + 5 × 2) × 15 ÷ 3? As we begin to depend on calculators and fail to master the simple laws of BEDMAS, we begin to lose a fundamental skillset. While likely unintended, consequences of this trend do exist. Mathematical errors can cause medical errors. Take dosage titration. A group of 28 trained physicians were asked to titrate a dose of epinephrine for a child in anaphylactic shock. As you can imagine, time was of the essence given this clinical scenario. To be brief, half the physicians had a bottle that more clearly explained the math than the other half, and naturally, more people in this half titrated the dose correctly. The morals of this story are two fold. First, label bottles clearly. Two, learn mental math. You don’t want to be that physician who incorrectly shifted a decimal place and gave a patient ten times the amount of opioid analgesics after their knee replacement surgery. As alluded to, the technology gurus of the century will likely come up with mechanisms of preventing medical errors that stem from math – and many already have. There are automatic mechanisms that flag medications with potential contraindications or incorrect dosages. However, every problem has 102 solutions. While technology can now be used to prevent the very problem it created (i.e. medication errors from math errors), the other solution is the

simple one – go back to the basics, master the math. Both treatment options are indicated for the disease of declining math. Overall, these points are not to undermine the progress of technology. Rather, they seek to serve as a warning.

"You don’t want to be that phy-

sician who incorrectly shifted a decimal place and gave a patient ten times the amount of opioid analgesics after their knee replacement surgery" And to humour you, let us point out some irony. The production of this article used spell-check 23 times to correct mistakes. Math is not the only basic skill dissipating. A selfcheck into one’s reliance on technology is likely the solution most appropriate for ensuring such basic proficiencies – math, reading, and writing – do not disappear entirely. Do what it takes to ensure the story of the calculator does not become the story of medical error. Perhaps you have been so inspired that you want to begin that self-checking process now. For that, we give you the following questions: 1. 2.

(12 × 15 × 6 + 4 × 6 × 15) ÷ 9 (5 + 21 – 4 + 18 + 26) ÷ 11 × 3 × 5 + 10

Sources: http://www.nytimes.com/2008/01/22/health/research/22lab. html

VOLUNTEERISM AND CLINICAL Mohammed Mohiuddin, Meds ‘21

As we approach winter, it’s the time of year that international volunteering organizations begin to recruit students to volunteer abroad in the summer. These programs advertise a unique, once in a lifetime experience to make an impact, to change the world, all while travelling to a new place. The programs provide a variety of destinations for students, from Cambodia, to Ghana to China. There are also various initiatives that students can participate in, such as building schools, teaching children, and working in orphanages. One would imagine that such a huge undertaking would require some sort of formal education, experience and skillsets, yet the only real requirement is having the thousands of dollars to fund the program and travel costs. These programs can even involve the opportunity to obtain clinical exposure for medical students by working in clinics or hospitals abroad in developing countries. Bright, young students offering their time and efforts as volunteers abroad, helping people in poverty, what more could there possibly be to say other than praise. However, I would like to offer you a different picture of this experience - the organizations mentioned above as members of the “Voluntourism” industry, and the students not as volunteers, but instead as volunteer tourists, or “voluntourists” for short. In any volunteering activity there is an intricate balance of giving and taking. The hope is that a volunteer, giving up their time and energy willingly, gives more than they take. The reality of voluntourism sadly is that voluntourists almost always take far more than they give back. The industry of voluntourism has numerous issues that can be discussed, but there are three main points I wish to touch on. First is the significant financial gain enjoyed by the organizations at the expense of oppressed people; second is the complete lack of preparedness of voluntourists; finally, the endemic poverty, racism and colonialism that continue to be perpetuated because of voluntourism. Most of the international voluntourism organizations require thousands of dollars to secure a spot in their programs. I found myself as an undergraduate student unable to even consider one of these trips, the cost being far too prohibitive. For some students however, personal funds along with fundraising initiatives allowed them to participate in these trips. Once voluntourists arrive at the destination, one common concern is that there is not all that much to do. Whether they are staying for a week-long excursion or several months, there are simply too many volunteers at any given time and not enough work to warrant such numbers. Voluntourists who remain in organizations for an extended period can speak to the lack of change in conditions despite more and more funding coming in as

more volunteers participate in the programs. It does not take critical thinking to realize organizations as being profit, and not humanitarian motivated. Now one may still be skeptical, after all, these organizations may be truly trying to make a difference. The most popular initiative that voluntourism thrives on is helping in orphanages in impoverished countries. However, orphanage tourism is a very controversial method of serving communities. According to Lumos, an international Britain based NGO, 90% of the 8 million children in institutions are not orphans. In fact, they have families that are fully capable of attending to their needs. Instead, these children are taken from their families and pushed into institutions due to pressure by voluntourism organizations, on the basis of poverty and discrimination. The “orphanage” and the “orphans” living within them is almost always a giant farce presented to young students to profit off their presence and give them a pat on the back for their time. These children remain in these orphanages year after year, receiving a scar each time a volunteer leaves them, after getting to know them only for a week. These same children are unable to see or be with their families, because that would defeat the purpose of the “orphanage” and prevent the need for these brilliant young adults travelling across the world and offering their time. Voluntourism does not exist without someone’s suffering.

"90% of the 8 million children in institutions are not orphans [...] these children are taken from their families and pushed into institutions due to pressure by voluntourism organizations" The suffering and hardship of the children that are forced from their families to be in these artificial environments is a price paid so that a very specific demographic of privileged young adults are able to feel that they are making an impact on the world, solving the problem of poverty and improving global health. It comes back to the idea of what volunteers have given vs. received. Could the thousands of dollars spent on travel and the programs not have been better off being put into the local economy in order to stimulate growth and

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EXPOSURE

provide opportunities for local workers? At the end of an experience voluntourists are left with a false sense of pride and accomplishment, the local population with suffering and pain, and the voluntourism organizations with heavy pockets. The second major issue with voluntourism is that it brings in students with hardly any of the relevant knowledge and skills needed to truly make an impact. If a voluntourist is going to be teaching children, they do not require any formal pedagogical training, no previous teaching experience, or even experience working with children in other roles. A voluntourist that will be constructing schools or buildings does not require any education on architecture, or any previous experience in construction. A medical volunteer doesn’t need to demonstrate their clinical acumen, simply being a medical student affords them the opportunity to enter clinical roles for which they are vastly undertrained. Perhaps even more significant than all of this is that voluntourists simply travel to the country and feel that no prior efforts are required on their part to be successful in their goals. They do not bother learning the language of the country they are visiting, nor the culture, history or

political situation. There are stereotypes of primitivism, poverty and dirtiness that fill the minds of voluntourists before arriving. This trend is quite problematic for several reasons. For one, students assume that simply their presence is what’s required to make an impact. It would be unthinkable to let an individual run a classroom for children here without the appropriate knowledge, teaching experience and language to work with children. Yet providing medical care to children and adults when you can’t even communicate in the same language seems perfectly normal in the context of international aid. It’s no wonder that many voluntourists find that the students can pick up on things like the alphabet very quickly. When the children are asked how they were able to learn so quickly they explain that the specific group of voluntourists are the seventh group that is teaching the alphabet. Perhaps worse are the building projects that many of the young students embark upon. After a seemingly productive day of building straight walls without a level, the local workers must come in at night time, tear down what was built by the students and repair it so that the voluntourists are able to continue the next day. They must do this in a way that the students don’t realize their work was fixed, because that would take away from their sense of accomplishment and pride. These projects once again take away from local resources, and rob the economy of jobs for local workers who may be able to properly and efficiently build the infrastructure needed. After a week filled with tours, dinners and social outings, volunteers providing “help” in artificial environments designed specifically for the volunteers,

"Providing medical care to children and adults when you can’t even communicate in the same language seems perfectly normal in the context of international aid" feel like they know exactly what needs to be done to solve the problems in these areas. With a complete lack of knowledge and understanding of anything about the country and region they are placed in, voluntourists aim to push their own understanding and experience onto the systems around them,

rather than stopping for a minute to understand and consider the differing culture and perspective of those living in these areas. It only serves to slow down growth and perpetuate the “white saviour” complex that has plagued these countries for centuries. Students are not engineers, doctors or carpenters that are able to provide skilled work in these areas. They are often looking for a way to pad their resume, a way to stand out from their peers for applications to professional school programs and of course get some travelling in while they’re doing it. After a week or two of staying in these countries voluntourists go back home having used orphans to get Facebook likes, taken away local jobs and a sense of having “changed the world”. But really, when you’re the 10th volunteer that has come to this area to do the exact same work for the exact same people on the same project that has been ongoing for years, what have you really accomplished? The final issue with voluntourism is one that extends far beyond any one individual, or even an entire country. Voluntourism allows colonialism, racism and poverty to continue existing at a systemic level within developing countries. Privileged, young students embark on a journey to impoverished countries in hopes of solving their problems and curing their diseases. After arriving these same individuals see the lives of people in these areas as primitive and deeply lacking. It’s almost frightening to consider how similar these motivations are to the colonialism that has led to oppressing entire nations and their peoples and their peoples. As long as these organizations exist, individuals in developing nations will continue suffering so that young privileged adults can have a go at fixing the world’s problems. However, instead of raising the quality of life, voluntourism creates inequalities and ensures that poverty continues within a region. It can almost be said that a volunteer tourist owes a debt to the people they served. After all, they provided the opportunity to the volunteer tourists to gain the experience. It can be easy to assume that we did a fantastic job and pat ourselves on the back at the end of an excursion, returning to our lives, having received awards, recognition and admission for our time internationally. However, if we are true to ourselves and our goals of wanting to truly make an impact in these countries then we must pay the debt and work to solve the issues taking place. Voluntourism is plagued with ethical

and moral issues that are far too exhaustive to discuss. Instead what we can do is change the culture and mentality when helping others both locally and abroad. Firstly, we need to accept that service doesn’t mean saving the world, it is not a transaction and it fundamentally requires respect. This respect extends beyond just basic respect for persons but also to their culture, history, political situation and their own way of doing things. Before we can hope to make a meaningful difference in the world, we need to educate ourselves on what it is we are trying to change and the best ways to go about doing so. Next, we can do our due diligence in making sure the organizations we work with are not thriving at the expense and suffering of the very populations we are trying to serve. This requires research, thorough questioning, and reaching out to previous volunteers. Lastly, we need to understand that our mere presence simply isn’t enough. In fact, it is probably far more damaging than any good we can do. It’s great to be able to travel and get some volunteering done, but in most cases, it simply isn’t doing any good.

"We need to understand that our mere presence simply isn't enough. In fact, it is probably far more damaging than any good we can do" Instead, initiatives such as fundraising, education, awareness and supporting current organizations through other means may be our best way of truly enacting change. There is quite a long way to go for current voluntourism as it exists today, before it can become something that does more good than harm. However, until we target the problem at it’s roots we will remain not volunteers but volunteer tourists, who take far more than they give.

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GIRL TALK! Roya Abdmoulaie, Meds ‘20

The following quotes are real clinical and/or professional encounters of racism and sexism as reported anonymously by Queen’s medical students. These reports represent a spectrum of experiences; from “micro-aggressions” which made women uncomfortable, to outright disrespect. The Creepy Patient Sick in more ways than one. Upon asking an elderly male inpatient at KGH how he was feeling: “Better, now that I have three beautiful women to look at!” --As a student begins the physical exam. Patient: “I wouldn’t mind having a pretty girl like you put her hands on me!” Tutor, to student, while laughing: “Sure, go ahead!” --Patient, to student: “Oh… If only I were 20 years younger…” The Questionable Tutor With great power, comes zero responsibility. Upon failing to illicit an Achilles reflex… Tutor: “I bet you can’t throw a baseball either!” --“While trying to conduct a physical exam, I was repeatedly interrupted by the tutor to have my male colleague demonstrate the skills to me, even though this colleague was meant to only be responsible for the history portion of the exam. I was consistently negatively critiqued, challenged, and cut off from doing any physical maneuvers, while the male colleague received instruction and support even when making obvious mistakes. After taking the patient’s heart rate, my male colleague was told to take the rate to determine if I got a correct value. When we reported what values we each got, the male’s reported value was significantly different than mine, and our tutor criticized me for being wrong despite having only the male student’s information. The nurse then came to take heart rate,

and confirmed that I had counted the correct rate. Ultimately, I was prevented from conducting the physical exam and it was instead passed on to the male colleague for practice. Later during the oral report, I was criticized as being ‘unorganized’ for reporting pertinent information that was forgotten in my colleague’s report.” --Regarding a nervous laugh… Male tutor, to student: “Your giggling isn’t going to help with anything.” --“During a clinical skills encounter, a patient repeatedly referred to me as a nurse and told me what a beautiful nurse I was. The Tutor never corrected the patient or clarified that I was a medical student, and would agree with the patient when they would make these remarks.” --“Our tutor would often encourage only the male students to pursue super competitive specialities, and would never ask about the career interests of his female students.” --“I have heard the male OR change-room consistently referred to as the ’doctors’ change-room, and the female change-room as the ’nurses’ change-room”. --“During a shift with a male attending, fellow, and resident, we were discussing a case while walking. Mid-conversation, they turned into the male changeroom and I could not follow. I missed the rest of the case discussion (which had originally been for my learning benefit) and ended up waiting 10 minutes, unsure which exit they would take out of the changeroom.” Your Friendly Neighbourhood Racist Ignorance is bliss! Elderly Caucasian KGH inpatient, to two women from the Greater Toronto Area: “So… are you gonna go back to your country after this?” ---

THERAPEUTIC Alisha Kapur, Meds ‘21 --Patient, to a student from a visible minority: “So, where are you from?” Student: “Toronto!” Patient: “No, where are you really from?” Student: “I was born in Toronto.” Patient: “So…Where are your parents from?” Student: “They live in Toronto.” Patient: “But… where were they born?” --Student: “Hello! My name is [non-western name]” Standardized Patient: “Huh. That’s a weird name.” --Three students—of whom two are not Chinese—walk into an elevator… Female visitor at KGH: “Oh look! Three Chinese girls. Are you from China? Do you speak Chinese? Can I practice speaking Chinese with you?” --After introductions… Standardized patient: “Listen, you need to enunciate your name, because it’s… complicated.” Situations that make you scratch your head In a “your-gaze-just-gave-me-a-venereal-disease” kind of way Two female researchers walk into a research meeting… Senior Physician: “Oh, is this Dr. X’s harem?” --Upon asking a question about radiology… Resident: “Oh, that’s so cute! Let me tell you all about how x-rays work.” --During an end-of-term performance review… Tutor: “Your skirt was too short and too tight at the OSCE!” Student: “Well, I was wearing pants at the OSCE…” ---

Medicine as a field is a whirlwind of constant education, skill acquisition, intimate exposure to others’ vulnerabilities and the management of oneself. As students, our goal is constantly trying to consolidate the knowledge and skills needed to become a good physician. As a resident, it is providing the care that each patient deserves while ensuring that your learning and well-being is taken care of. As a staff physician, it is learning how to balance career goals and time with loved ones, while still providing excellent quality patient care. Regardless of the stage of our careers, it is easy to feel like each day is melding into another. A week becomes a blur and suddenly it is difficult to isolate different events within a month or even a year. Such fast-paced learning requires constant reflection in order to parse out important lessons learned from everyday events. It should therefore come as no surprise that medical education has recognized the importance of reflection as demonstrated by the integration of narrative medicine into the curriculum. Often, narrative medicine takes the form of reflective writing, whether it is reflection of a day, week or event. The practice of such writing allows us to remember the art of medicine and examine the relationships we hold with our patients and even our colleagues. Personally, I have tried the “dear diary” approach to journaling many times over. Every night becomes an attempt to personify your journal, to energize mundane events that compromise your day; however, for me the “dear diary” approach was never effective. Upon the start of medical school, I started using my journal as a “parallel chart.” “Parallel charting”, was a concept coined by Rita Charon, a professor of internal medicine at Columbia University. Dr. Charon is the founder of the program of Narrative Medicine at Columbia. She advocates for the use of reflective writing in the practice of medicine. Parallel charting, according to Dr. Charon, is essentially an opportunity for physicians to take the patient’s perspective.The goal is to remind physicians of the humanity intrinsic in medicine, and the story beyond the clinical presentation.

Essay

BENEFITS OF JOURNALING IN MEDICINE "Parallel charting, according to Dr Charon, is essentially an opportunity for physicians to take the patient’s perspective. The goal is to remind physicians of the humanity intrinsic in medicine, and the story beyond the clinical presenation" As a pre-clerk with few patients to reflect on, I still found this approach useful in facilitating effective journaling. Viewing situations from a separate point of view enabled me to write about any conflicts, or events from another’s eyes. The use of parallel charting, or journal writing, is a fantastic environment to discuss any issues that might be troubling. It gives us the ability to write about such events in a non-judgemental environment and perhaps even formulate coherent thoughts on them. For anyone considering starting a journal, anytime is a good time to start. Do not wait until the new year, or until the start of clerkship or residency because insight from each and every stage in your life is valuable. Below are a few tips to help you get started: •At the end of every day, take 10 minutes to mentally go through the events of your day. Include the classes you attended (or did not attend), what you wore, interesting conversations you had or anything that stood out to you.

•At the end of the week, write down any significant events that occurred that week in your journal, any reflections or lessons learned, or any epiphanies. •If needed, conduct some research and read articles about the topic. •If you prefer to use your journal as a parallel chart, start by writing about one significant experience, or patient, at a time. •Remember to keep away from the medical aspects of the patient and focus on setting the stage. Try to write about the environment, the sounds, smells and feeling. •Move towards describing any emotions and life details that might be experienced. By focusing on creating the story of a life, you will eventually create a narrative. •If you prefer to use your journal as a parallel chart, start by writing about one significant experience, or patient, at a time. •Remember to keep away from the medical aspects of the patient and focus on setting the stage. Try to write about the environment, the sounds, smells and feeling. •Move towards describing any emotions and life details that might be experienced. •By focusing on creating the story of a life, you will eventually create a narrative. •This may sound obvious, but tell the truth. Your journal is a space of non-judgement. Writing what actually happened and what you felt helps provide an out of body and holistic view of a situation. The final tip is to start writing and keep writing. Writing and keeping a journal is not as hard as we make it to be. It takes practice, but is extremely rewarding in the end.

Creative

ADVICE FOR MY MOTHER, 28 YEARS AGO Ramita Verma, Meds ‘20 1. You can say no. Our family reputation

12. When he raids your office to get you

will recover.

fired, fight back. Your 9-5 is worth more

2. When you move across the world, you

than a paycheck.

don’t have to eat Froot Loops for breakfast.

13. When he rips your son away from you,

Learn how to make paranthas.

believe that you will see him again.

3. The letters behind his name, M.D., will

14. Your children will be friends again, give

damage instead of heal.

it time. Don’t feel guilty about it.

4. He watched his father beat the love and

15. You will make a mosaic of stained glass

peace out of his mother – it is his only un-

from all the broken pieces. Your light will

derstanding of marriage.

bring color into my life.

5. You will be okay.

16. Your strength is where I get mine.

6. Eventually you will stop craving the

17. There will be a day when you tell your

smell of Bitu Tikki Wala’s street food, the

kids that we cannot afford pizza lunches.

snow will sting less, and this foreign land

Then, there will be a day when you tell your

you left your soil for will become home.

kids to pick from New Arrivals at Lulu-

7. Do not let him control you.

lemon.

8. The kids are equally yours. The home

18. When the man that put you in the hos-

is equally yours. Your friends are equally

pital has a heart attack, send him flowers.

yours. Perhaps even more so.

Keep forgiving.

9. Call your mom and talk to her freely. He

19. Don’t lose faith in love. The next man

may be listening to every word, you may

will be who you always deserved.

feel afraid, but she is your mom.

20. The best revenge is success. Build your

10. No matter how forcefully he grabs you,

empire, no matter what age you have to

do not have the abortion because I am a

start at.

girl. Not again.

21. Know that every single part of you is

11. Visit home as often as you can. He

inspiring, motivating, and an aspiration.

won’t join you, but it’s important for the kids to meet their family.

Review

BOOK OF THE ISSUE DYING: A MEMOIR IS THE HOW-TO GUIDE WE ALL NEED Maggie Hulbert, Meds ‘20 “I went through most of my life believing that death was something that happened to other people.” This is one of the many resonating insights author Cory Taylor provides to the reader, chronicling the transition from one of the living to one of the dead, and her time spent in the space between. And she is an expert: she has spent the past ten years dying slowly of metastatic melanoma, and at the encouragement of her publisher, wrote her final memoir on the process. The result is a beautiful piece on what it’s like to die, and will join the ranks of Being Mortal and When Breath Becomes Air as a foundational reference on palliative care and the humanity required when caring for the dying. However, unlike these two tomes, Dying: A memoir is not written by a physician, and the complete lack of medical language is a refreshing and significant part of this book’s contribution to the field. It also underscores an important part of Taylor’s work, which is to reclaim dying as a human process, not a medical one. Taylor writes passionately about her desire for the legalization of assisted suicide in her home country of Australia. In one moving passage, she describes how she would ideally like to go: after a party with all her friends and family, in the arms of her husband in their home. Written in the context of the previous chapter describing the arduous process of accepting her death, it is impossible to see anything pathological about her desire. Indeed, her most significant anxiety at the time right before her death was her medical care somehow prolonging her death, which she said she would be glad to have over. While Canada has recently legalized physician-assisted suicide, Taylor’s work highlights that the process is still quite medicalized. Given that Taylor’s dream could not be realized in Canada, despite these very recent advances in end-of-life care, it is clearthat we are still taking away significant choice from our palliative care patients.

its entirety to help others along the way. She touches on the meaning of her death as a way to say goodbye, and writes frequently about the plans she is making with her family for after she is gone. While the grief her husband and two sons must have experienced after she passed cannot be devalued, one must think that it is easier knowing they are doing exactly what their loved one wanted and wrote down. Is this not what we all want in the end? By far the most unique part of Taylor’s work is the chapter where she gives her answers to a TV interviewer’s questions on what it’s like to die. The questions, which she describes as “unsurprising”, ranged from trivial things like “Do you have a bucket list?” to the more meaningful “Is there anything good about dying?” Reading these frank, honest answers to questions most have thought and few can answer lifts a veil of mystery off the process of dying. It seems so simple, but dying is often regarded as a secretive, shameful experience, to be left for grieving families to deal with in private. Taylor succeeds in accomplishing her goal of “winning back some dignity for the dying” by giving us a chronicle of her thoughts, feelings, and coping strategies for the end that comes for us all.

Many palliative care lectures begin with the age-old question, what makes a good death? Taylor’s work is our answer. She uses time that many would have seen as an unbearably prolonged death sentence to live her life the way she always wanted, reflect on where she had been, and chronicled the process in

UNSPOKEN Sharon Yeung, Meds ‘21

Growing up, I was taught that timeliness is next to godliness. To be five minutes late was acceptable, but only if not habitual. Bells and buzzers signalled the start and end of first period, recess, and a “full night’s” sleep. Eventually, I was habituated and I would move without needing sound at all. In my university years, my consciousness of timeliness facilitated my tendency to skip class: surely the introduction was so vital that I would never be able to follow along if I missed it. In those years, I conversely learned that tardiness was a fashion statement. Showing up on time to a party was unfathomable – practically social suicide. “Fashionably late” was one of those social constructs I never quite understood, and I never thought it would matter. Until it did. I couldn’t decide if he was being fashionable, or just rude. I tapped my foot impatiently on the pristine vinyl flooring, glancing at the clock on the wall for the third time that minute. I glided in and out of consciousness.Two thirty-seven. How long have I been here? Is there still money on my parking meter? In the corner of the desk, a plastic model teetered with every tap of my foot. Looks like a right knee joint. I labelled the ligaments and bones in my head. Patella. Medial epicondyle. Medial meniscus. Posterior collateral ligament? Was it collateral? That doesn’t sound right. I waited. Two fifty-nine. The door opened quickly, revealing a middle-aged man in a wrinkled white coat, with thinning, grey hair. I nodded in his direction, but he was immersed in the chart – probably my own.

He glanced at me and mumbled an introduction. Dark eyes, pointed nose, thin lips. Average height. Prominent cheeks, and dark circles under the eyes. He shook my hand briefly, barely grasping my palm. And then he sat, finally looking me in the eye. “What brings you in here today?” The moment I had his attention was a paradoxical one. The man whom I had waited over an hour to see had finally waltzed in, and I suddenly wasn’t quite sure what to say to him anymore. Why am I here again? Who sent me here? Am I wasting his time? He looks busy. Intimidation filled my consciousness, even though I was acutely aware that I would one day be in his position. This is the man who will be able to help me. Don’t screw it up.

“Navigating the health care system is more than a journey of medical care; it is a journey through the most withheld, yet complex and intimate emotions.” With urgency, I removed my shoes and socks and showed him my right foot. It had been bothering me for about a year now. My big toe was disfigured; my nail bed was crooked and painful with pres-

sure. It looked like the nail bed was being displaced by bone, cocking upwards in such an angle that the sharp edge of the nail had torn a hole through every pair of Toms that I owned. This was the fourth specialist I was seeing, and the third waitlist I’d been on. This appointment had been on my agenda for months, circled and re-circled in pink highlighter, as obnoxious as the bell and the buzzer that couldn’t be missed. He has no idea. He examined my foot, gingerly picking at my toe and asking if I had gotten X-rays done. I have. Two sets, actually. That wasn’t good enough. I needed another set. Are you serious? I didn’t argue. I smiled pleasantly, knowing that I would one day hope to have pleasant patients too. He told me that he thought I would need surgery. What kind of surgery? Will it hurt? When will that happen? He didn’t elaborate. But I’m supposed to be writing my MCAT this summer. I nodded, as if it was no big deal. I made a mental note to find the answers on Google when I got home. He thanked me for coming in and asked me to make another appointment once I had gotten a new set of X-rays. I can’t remember his name. Eight minutes – or was it ten? As briskly as I had heard the door creak open, I heard it click shut resolutely behind the billowing of that wrinkled white coat. The plastic knee joint gave a gentle totter and settled back into its place. It was as if he had never come. I knew that I would be back in this exact chair, in this exact room with the pristine vinyl flooring and plastic knee joint and languid wall clock

Essay

in just a few months. I knew that I would be on time. I’ll probably be the pathetic, early guest again. And he’ll be fashionably late. I felt nauseous. A few minutes passed and I mustered the strength to walk through walk through the waiting room towards the door, where dozens of patients sat quietly. An elderly gentleman sat near the door, tapping his foot. I met his gaze and we connected in a fleeting moment of shared understanding. Good luck. Navigating the health care system is more than a journey of medical care; it is a journey through the most withheld, yet complex and intimate of emotions. Cascades of emotion that are not attributed to any lack of understanding of how the system works, or lack of basic medical information. My education has privileged me to possess both of these bodies of knowledge. In spite of this, the prospect of being ill and of needing treatment is vastly disorientating and terrifying, even if you understand the position of every bone that’s been dislocated or every cut that the surgeon’s scalpel will make. Time freezes. You can’t remember how long you’ve been sick, or how many months you’ve waited to see the specialist. Anticlimactic appointments come and go, and you’re diagnosed, and then re-diagnosed. Your sense of self changes. In your subconscious, you tell yourself that you know your story the best. But I’m scared to tell it. What do I really know about medicine? Doctors know best. Yesterday marked two months since I started medical school, and in some ways,

I already fear that I have forgotten. The dichotomy we delineate between doctors and patients propels us to forget that we share a common humanity. Disease plays no favourites, and illness creeps upon those most unsuspecting, those most invincible. I try to remind myself frequently of the frustration, helplessness, and fear that gripped me as I endured waiting room after waiting room. The

“The prospect of being ill and of needing treatment is vastly disorienting and terrifying, even if you understand the position of every bone that’s been dislocated or every cut that the surgeon’s scalpel will make.”

throat - I think about my future patients. The waiting rooms. The toe tapping. The memorization of every poster in my clinic room. I wish I could apologize in advance. In spite of this – or perhaps, because of this, I resolve to continue paying homage to the terror of illness and the imperfection of the system, to the emotion, spoken or unspoken, in every patient encounter. I resolve to remind myself that the fiftieth broken bone that I’m seeing may be my patient’s first. That it’s scary. I will remind myself that the hospital’s silent smell of life and death, veiled in antiseptic, is petrifying if you don’t smell it everyday, and that vinyl flooring is squeaky and uncomfortable. When the examination room door clicks shut, I resolve to look my patient in the eye, to acknowledge the emotion within and the humanity we share. I resolve to introduce myself, even if they’re too nervous to remember who I am. And then, most sincerely, I resolve to thank my patient for their patience.

animosity I had for every non-chalant physician who acted as if my condition were a simple papercut. The shadows and the implicit frailties of our universal health care system. I try to remind myself of how illness changed the way I see myself – of how it jaded me. And then – holding raw emotion in my fist and swallowing the lump in my

A PERSON, IN Scott Wakeham, Meds ‘20 about grief and loss.

“Every doctor that I’ve met has been quick to judge... but we are much more than our diseases.” “My name is Scott, and I’m a medical student” Shit. Had I already fumbled? Having heard introductions from alcoholics and addicts, I felt that the use of my title was a cop out. Minutes after arriving at the Betty Ford Centre, I find myself sitting in a circle with a group of patients whose stories and knowledge of addiction far exceeded mine. I feel selfish as I merely share an introduction that I would at a conference, while the others in the circle share personal details. Next up: group therapy. “I’m here for a tune up” “What do you mean by a tune up?” “Well - I had been sober for a year and a half, and then I had a binge that landed me in the hospital. I need a tune up” In no fewer words did I feel stigma surrounding addiction become broken. Just as the heart failure patient can decompensate, the COPD patient experience an acute exacerbation, this woman was here for maintenance. Although abstinence based programs for drugs and alcohol can be controversial in both long-term outcomes and safety (and frankly, I’m still unsure where I stand with them), the success for certain people cannot be denied. Many staff of the centre are alumni of the treatment program and have maintained sobriety for years. Some even longer than I’ve been alive. The session ends abruptly but with a chance to share any last thoughts or feelings. I collect my thoughts and take a moment to admire the lines that the hills surrounding the centre make against the blue sky on my way to a group therapy session

“I just got a call from my roommates. I’m trying to keep it together, but they just told me that they sold my dog to pay for rent for the upcoming month” I have never felt so welcome and immediately trusted as I had in my small group. People tell stories of their survivals of sexual violence, episodes of abuse, lack of social support, and other events that made me wish I had much more to offer than my presence as a learner. As we make it around the circle in grief group, I feel compelled to share my personal stories of grief and loss. Perhaps this component of addictions treatment wasn’t limited just to addictions. Airing our darker and less talked about spaces allows me to connect with these people on a deeper, more personal level. We share loss, love, hope, and eliminated the “othered-ness” between us.

Essay

CONTEXT Days come and go. Meals are eaten with our small groups, and the light conversation ebbs and flows between Netflix, hiking, and what the future has in store. At one of my last lunches in the centre, a group member turns to me. “If I can wish one thing for your career, it’s that you remember these conversations and this experience when you look in your patient’s eyes. Every doctor that I’ve met has been quick to judge, and maybe you’re trained to be that way, but we are much more than our diseases.” Having shared stories, I understand that addiction is so much more than a disease. Although I realized this through reading books by Gabor Mate, facilitating correctional addictions treatment as a pharmacist, and experiencing addiction within my family, I had yet to actually understand it. Unfortunately, I’m still not able to define what it is. I understand that it is much more than a disease, but in what way? And how can I provide the best care with this in context? Maybe it is so difficult to define because each story and storyteller are so unique. The best we can ever hope to do is share our empathy, compassion, and understanding.

“Airing our darker and less talked about spaces allows me to connect with these people on a deeper, more personal level. We share loss, love, hope, and eliminated the “othered-ness” between us.” For more information on the Summer Institute for Medical Students (SIMS) program at the Hazelden Betty Ford Foundation, visit http://www.hazeldenbettyford.org/education/medical-professional-education/summer-institute-medical-students

HOW I LEARNED TO HEAL Palika Kohli, Meds ‘21 nestled in a mountainous valley in north India there is a city that once was a town it is called Dehradun this is where my papa was raised papa grew up with music in his bones it is in his bearing in the way his eyes crinkle when he smiles sometimes, when he is being absent-minded he begins to sing out our conversations until we stop and listen to the words we just have spoken, echoing back at us papa’s music is alive in him it is a palpable thing but often you don’t notice it until it’s gone when he’s tired, or hungry, or sad like a hum in the air that suddenly disappears, the loss of papa’s music is heavy you don’t fully recognize what has changed, only that now your every movement and breath and word feels louder sometimes, you can’t hear it because he has surrounded himself with louder music that is harmonious with his own. this can be particularly distracting, until you notice papa staying afloat to the tune of what he’s playing. he will hum, or murmur, or sing along, otherwise engrossed in his work when he was younger, papa saved up and bought himself a cassette player the first in his family. the first cassette he bought was for his grandmother, of religious bhajans that she listened to every morning before returning the player to him now, papa has a TV in his bathroom a movie theatre in his basement a surround sound system in his study (that he installed himself while our home was still being built) so that wherever he goes, he is never without music

Creative

this is how he learned to heal. on the edge of Lake Ontario, just outside Toronto there is a city that pretends to be a town it is called Ajax this is where my siblings and I were raised when we were younger, papa would play the cassette of our current favourite Bollywood film. the music would blare on his sound system and he would set up our camcorder to film us. we would dance in front of the TV, watching ourselves on screen, until we became exhausted and fell asleep papa has taught us that the best way to study is with a soundtrack and there are still entire albums that remind me of family road trips we took years ago on long drives, I often act as DJ and have curated playlists of music that span more than four decades. in university, papa and I would sing along as he drove me to a final exam, belting out the lyrics to songs like Palash Sen’s Maaeri and Ed Sheeran’s Give Me Love. sometimes, he turns on the Karaoke machine he bought and starts singing at us until we leave our rooms, laughing and begging him to stop when I am down tired or confused or hurt papa brings his music to me he sings hello on the phone or plays me a bhajan, for strength and serenity or brings chai and biscuits and almonds and fruit to my room and talks with me until I forget my melancholy my friends and I have impromptu Bollywood dance parties my siblings and I blast reggae and soca and Bhangra whenever we go on drives together my best friend and I exchange songs over Whatsapp my brother makes videos of us to the tunes of our childhood my sister plays her current favourite song on repeat for weeks at a time my mother wakes us up on the weekends, singing the Aarti and late at night, when I can’t sleep, I turn on Arijit Singh’s Kabira or the Hanuman Chalisa until the world fades out around me this is how I learned to heal.

HOW DID WE END UP

A S H O R T C H R O N I C L E O F H E A LT H & I L L N E S S Bryan Franco, Meds ‘21 Give us [in medicine] a disease, and we can do something about it. But give us an elderly woman with high blood pressure, arthritic knees, and various other ailments besides – an elderly woman at risk of losing the life she enjoys – and we hardly know what to do and often only make matters worse

Society had to rely on social progress, such as better standards of living, to achieve what medicine could not—improve health of individuals. Improvements in socioeconomic factors, rather than medical innovations, pushed human – Dr. Atul Gawande in Being Mortal (pg. 44) describing how physicians often history into the age of receding pandemstruggle to care for elderly patients with comorbidities who represent a growing ics. This age was characterized by an enduring decline of infectious diseases proportion of the population. and childhood mortality, causing life expectancy to increase to 50 years by the How did we end up here? The short ine, life expectancy at birth was short twentieth century. With the rare excepanswer is that medicine is a victim of (around 18 years in ancient Rome) and tion of smallpox, vaccines and medical its own success. And only after under- fluctuated widely in response to pan- care continued to be futile in reducing standing how we got to this point can we demics and wars (Omran, 2005). Until mortality. begin realigning medicine to best serve around the mid-seventeenth century, our patients. infectious diseases (think the plague), Medicine finally found its niche with chronic malnutrition, maternal and peri- advances in science and countless innoEpidemiologic transition refers to a natal complications, and trauma (imag- vations during the age of degenerative change over time in life expectancies ine death by arrow) subjected people and human-made diseases. In the last in populations and the drivers of that to short lives punctuated by periods of century alone, prenatal and maternal change. There are three consecutive tran- extreme morbidity, for which medicine care vastly improved, antibiotics became standard treatment for infections, and sitions: the age of pestilence and famine, was often futile. highly skilled trauma teams assembled the age of receding pandemics, and the in emergency departments ready to leap age of degenerative and human-made into action. Canada embraced the success diseases (Omran, 2005). Epidemiologic of medicine, as exemplified in the Canada transitions shed light on our journey Health Act of 1984 which requires physitoward a system where society’s brightest cian and hospital services to be publicly and most compassionate care providers financed (Lewis, Donaldson, Mitton, & work with the most advanced technology Currie, 2001). We invested heavily in in towering hospitals and shiny operathospitals, physicians, and therapies to ing rooms, yet still struggle to care for a treat patients with promising results. growing number of patients. Between 1990 and 2010 in Canada, life expectancy rose from 80.3 to 82.7 years If nothing else, epidemiologic transiand 74.0 to 78.5 years for females and tions provide us with a dose of humility males, respectively (Salomon et al., 2012). in an era where machines can breathe for us if our muscles fatigue and where However, the newfound success of mediscience allows us to manipulate DNA. cine meant that less people die from acute They remind us that medicine has played diseases and that more people are living a miniscule (and that’s being generous) with chronic illnesses—quickly pitting role in improving health. Much of what the very traditions that made medicine lifted our society from the turbulent cysuccessful at odds with the needs of pacles of universal suffering was unrelated tients. For example, hospital wards are to innovations in medicine. purposefully organized by organ system or specialty, a design that excels in treatDuring the age of pestilence and faming patients with a specific type of disease.

"Epidemiologic transitions provide us with a dose of humility in an era where machines can breathe for us if our muscles fatigue and where science allows us to manipulate DNA"

Essay

HERE? For most of the last century, we were confident that patients can recover in hospital after we treated their fracture, infection, and other acute diseases. Today, our confidence wavers in the face of elderly patients with multiple chronic illnesses, for whom medicine’s traditions, such as prolonged bedrest in hospital, are hazardous (Creditor, 1993). After just a century of initially finding success, our ingenuity has created a medical system that helps people live longer than ever before. As a result, we find ourselves at the cusp of a new epidemiological transition that requires medicine to evolve to meet the needs of a current era characterized by extended life expectancies and chronic illness (Salomon & Murray, 2002). We are at an exciting time in history. The same principles of science and innovation that allowed us to successfully treat patients can and must be used to also treat our health care system. Failure to do so risks medicine slipping back into futility where it lingered for much of human history—leaving us asking “how did medicine end” instead of “how did we end up here?” References

1. Creditor, M. C. (1993). Hazards of hospitalization of the elderly. Ann Intern Med, 118(3), 1-223. 2. Gawande, A. (2014). Being mortal : medicine and what matters in the end. 3. Lewis, S., Donaldson, C., Mitton, C., & Currie, G. (2001). The future of health care in Canada. BMJ, 323(7318), 926-929.

4. Omran, A. R. (2005). The epidemiologic transition: a theory of the epidemiology of population change. 1971. Milbank Q, 83(4), 731-757. doi:10.1111/j.14680009.2005.00398.x 5. Salomon, J. A., & Murray, C. J. L. (2002). The epidemiologic transition revisited: Compositional models for causes of death by age and sex. Population and Development Review,

28(2), 205-+. doi:DOI 10.1111/j.17284457.2002.00205.x 6. Salomon, J. A., Wang, H., Freeman, M. K., Vos, T., Flaxman, A. D., Lopez, A. D., & Murray, C. J. (2012). Healthy life expectancy for 187 countries, 1990-2010: a systematic analysis for the Global Burden Disease Study 2010. Lancet, 380(9859), 2144-2162. doi:10.1016/S01406736(12)61690-0

2017 DIARY S Anonymous, Meds

September 22, 2017 Today is supposed to be a good day. It ticks all the right boxes: white cotton clouds, clear blue sky, 4 hours of class, and on top of all that, it’s a FRIDAY. But here I am, sitting in my room flooded by bright sunlight, with tears stinging in my eyes. I feel so…sad, and then from sadness grows even greater confusion. When did I become such a crybaby? Potential answer: when I became a medical school student at one of my top choice schools. This entry is not going to be filled with inspiring revelations and tales of new friends or love interests in a new city. Instead it is going to be about the banes of my current existence: A silent apartment when my roommates leave. A schedule that is impossible to keep track of, day to day, week to week. An inability to travel anywhere without the assistance of Google Maps. My commute home is now a 3-hour commitment, market valued at $50-60—one way. That’s one pair of clinic shoes, three meals, and about 23 tall Starbucks coffees (let’s not try to fathom how many Tim Hortons that equates to). But perhaps what weighs down on me most is a loss of identity. I can write a complete profile of myself from undergrad. Adelaide Sutherland: 4th year student, President of the Arts & Science Student Union for one half of my life, spent the other half on immunotherapy research. I roamed UofT’s campus like I was born and raised there, and embraced my reputation of being late to most things (which I recently learned is the worst breach in professionalism I can now commit). Not a medical school gunner, but certainly a keener.

Who will I be in Queen’s medicine? The “I know what specialty I want” gunner, a highly involved QMed community member, the person who tries to be everyone’s friend but ends up being nobody’s? Possibilities are endless. So are stereotypes. Maybe first year is difficult not because the courses are overwhelmingly difficult (although it sometimes feels that way), but because I struggle to grasp my place, my environment, and my learning style. That, compounded with being surrounded by 100 other brilliant classmates who all seem to know theirs. I know this sounds ridiculous—and my past self will slap me for even writing this—but part of me thinks that getting 82% on my last test (aka. below average) when I thought I did pretty well on it is the last straw. The last straw confirming “Clearly I do not know what I am doing,” added to a heap of emotions. There are certainly good times. Catching a foosball game between classes, running through rain to Tim Hortons with my classmates, times when I would not want to be anywhere else. Only these times come and go. Like waves. If only they can stay, if I can get some reassurance that everything will not just be okay, but that it will be beautiful… Perhaps that is asking for too much. Yours, Adelaide

Creative

SERIES November 4, 2018 I am sitting in Nathan’s car, on a drive back to Kingston. I just need a mini debrief with myself. How should I start? Second year is pretty sweet. What a shock right? Bet you thought I was going through another crisis, given that 90% of my diary entries start with melodramatics. My class is funny, talented, and (I don’t want to drop this overused term but there’s really no other word) actually inclusive. I met upper years who I can count on for advice, found role models in mentors, and made a solid group of friends who have my back for any disaster. Over the past year and few months at Queen’s, I slowly poured myself into a mould that is gradually forming at the same time. Amateur water polo and foosball player, star dancer, Anesthesia Interest Group exec, longitudinal exam studier. Winning small victories against my reputation of being late. I still don’t know exactly who I am, but I feel…centred. I scaled the wall of imagined embarrassment in pressing the intercom button, and after episodes of complaints, learned to trust the curriculum. Second year fills in the blanks that are left in first year. Finally, we are taught to think like doctors (or the way I imagine doctors to think). Last week we learned about pneumonia— clinical presentation, which tests are useful and how results should alter our suspicion, management. Then we went to the hospital during our extended clinical skills and listened to the lung crackles of someone with pneumonia. Pretty amazing. So why am I in need of a debrief? The problem is, I feel like a jellyfish. I am a jellyfish floundering between specialties that fall under “primary care” when it comes to career planning. Because my courses are suddenly 10 times more clinically relevant, I feel a need to master them. Need or desire? It is hard to tell. After all, I want to become a good physician and I will need clinically relevant knowledge to become a good physician—or just any physician, period. At the same time, this is

the last year before clerkship. I am pressured to ponder not only which specialties interest me, but also levels of competition, job prospects, accompanying lifestyles, and what that means for starting a family. Yep, I am indeed also thinking about how I would like to start my imaginary family. All while trying to remember the tests that should reasonably be ordered for the differential diagnosis of emphysema. The struggle between career exploration and investing in academics is constant. Secretly, I know I over-invest in academics because it is easier—I know how to learn but I really don’t know how to find “my calling”—and because my brain demands a high level of familiarity with a subject to feel satisfied. If I’m to have hopes for narrowing down my choices further from “I think I like primary care”, I have to get over both these mental hurdles. Second year is like puberty. Strange analogy, but bear with me. I am no longer a fresh first year, but am far from managing patients. Knowing much more, but not enough. The transition between pre-clerkship and clerkship, childhood and early adulthood. I am learning to be grown up and deciding what to grow towards. The days are long and packed, but weeks are short. Months, even shorter. How is it November already?! Here’s to hoping the years will at least be semi-long. I love QMed too much to leave too soon. Yours, Adelaide Goals: (time to heed my advisor’s advice) 1. Less studying, more observing 2. Soul search 3. Make time for friends

2017 DIARY October 30, 2019* *Not a diary entry due to lack of time for writing one. This is Adelaide’s recount 4:32 PM. I glance at my watch before stepping into room G326. Times flies so fast on the inpatient unit that I’ve developed a reflex to try (and fail) to keep it in check. I visit Mr. Constalez in bed B for the second time today. 57-year-old, referred from Emerg for congestive heart failure and COPD exacerbation five days ago. He developed a cough yesterday and started running a temperature bordering on fever this morning, so I asked to order an X-ray.

monia, the patient has risk factors for resistant pathogens… we should probably get him started on a combination therapy. Cefepime, ciprofloxacin, and linezolid? I’ll discuss this with Joe, the senior resident, when he comes back from Timmies. In the meantime, I update the EMR for Ms. Kravitz, a patient who was admitted early afternoon with suspected delirium: “This is Adelaide Sutherland, last name S-U-T-H-E-R-L-AN-D, MS3, dictating on behalf of Doctor Matthew, last name M-A-T-T-H-E-W…” When I hang up the receiver, I feel a tap on my shoulder. “Why are you still here? Go home!”

That should be ready for me by now.

I swivel around and see Joe grinning at me, coffee in hand.

I make a mental note to check his EMR soon. The darkened lights and shut blinds signal to me that Mr. Constalez may be asleep. I wave a silent greeting to Ms. Gupta in bed A, and carefully step around the green separation curtains. A much-needed nap. I pause a moment to observe the white sheet move up and down with the rise and fall of his chest. He looks too peaceful for me to wake him just to ask a few questions about his cough and the swelling in his legs, so I settle for checking the vitals monitor. Arterial oxygen saturation is within safe range, but still on the lower end. I’ll drop by again before I leave.

“Just trying to be keen like you,” I joke. “But don’t worry, I’ll be out soon, I promise. Can I get your opinion on an X-ray?”

I return to the nursing station to access the X-ray results. Hmm…

“Hey that’s OK,” Joe read my expression. “She seems stable for now, ask her tomorrow morning. Go home and get some rest.”

One thing you quickly learn during clerkship is that medicine is never cut and dry the way you were taught in lectures and texts. I squint at the screen for a second time.

6:18 PM. I breathe in the crisp air before stepping onto a pavement littered with crumpled leaves. The asphalt gleams with orange sunset. I picture nightfall and all motivation to go to the 8:00 yoga class escapes. Finding time and energy for hobbies is a real battle in clerkship. Eating, watching Stranger Things, then reviewing common medications implicated in delirium are the only activities that appeal to me right now.

If I stare long and hard, I can convince myself the blurriness in the upper right lobe is an indication of pus accumulation. But I also cannot convince myself it is normal lung. My brain immediately runs through a schema: Hospital-acquired pneu-

He agrees with my suspicion for pneumonia. Then I present my diagnostic work-up for Ms. Kravitz. “Did you ask about ibuprofen?” Shoot. I wanted to face palm. How can I forget to probe about medication use??

Creative

SERIES I want to do well in this rotation because internal medicine is a specialty I am interested in. But at the same time, something the Junior Attendant once told me rings true: Work in the hospital is like gas. If you do not contain it, it will expand and fill every space you have in your schedule. Even so, it hasn’t been as overwhelming as I imagined. The residents and staff are all phenomenally supportive (note my word choices— “great” wouldn’t even do them justice). They are always understanding, willing to teach, and watch out for my wellbeing more vigilantly than I. Under their guidance, even within 4.5 weeks, I transformed from an anxious clerk, determined to impress, to a student who is comfortable expressing uncertainty and asking for help. When I start my next rotation, it will be like starting from square one: new team, new schedule, new workload. Almost. Only this time the small voice in my head will no longer be freaking out over the one million + 1 things I do not know yet. Instead it reassures me. “I have to do this and have done it once, so I will figure it out.” If second year taught us to think like physicians, clerkship is teaching me to be one. I imagine this continues through residency, but imagination I learned—especially when it comes to predicting your medical training experience—often misses the mark. I for one, imagined that there is a beginning, middle, and end to medical education. First year, second year to clerkship, then a residency finale. But the more I progress through it and speak to residents or staff alike, the more I understand what the physician competency guidelines mean by the words “lifelong learning”. Learning medicine lifelong. I committed to it three years ago when I accepted my offer of admissions, and it is here to stay. Thankfully there is nothing else I would rather do.

INTERVIEW: DR ANTHONY DR ANTHONY SANFILIPPO

Shubham Sharma, Meds ‘21 Dr. Anthony Sanfilippo is currently in his third term as Associate Dean of Undergraduate Medical Education, Faculty of Health Sciences at Queen’s University. Dr. Sanfilippo graduated with his Bachelor of Sciences in 1976 and Doctor of Medicine in 1981, both from Queen’s University. Dr. Sanfilippo then undertook residency in Internal Medicine at Queen’s, became Chief Resident in Internal Medicine in 1984, received his Royal College Fellowship in 1985, and certification in Cardiology in 1987. He subsequently went on to do a postgraduate research fellowship in Echocardiography at the Cardiology Unit in Massachusetts General Hospital, Harvard University School of Medicine in 1989. Since then, he has been a clinical cardiologist with Hotel Dieu Hospital and Kingston General Hospital, directing Echocardiography Laboratories at both locations. He also holds a teaching position with Queen’s University as a Professor of Medicine and Cardiology. As Associate Dean, he also started the Undergraduate School of Medicine Blog and contributes to it on a regular basis. In this interview, QMR’s Shubham Sharma sat down with Dr. Sanfilippo to discuss the motivation behind his blogging and how it has affected him, his patients, and his peers. QMR: We, QMed students, are quite familiar with your blogposts on the Queen’s University website. Personally, I find your approach to blogging quite unique and interesting for a blog dedicated to the university. I am curious as to when you first began blogging and what made you start. AS: I think it first began 4-5 years ago. The initial motivation was very practical – I was looking for ways to communicate more broadly with the students and the faculty, and I found that it is quite hard to get messages out to everybody. So, I spoke with the medical technology people and they came up with the idea of using a blog to post messages. It started out as a very pragmatic way of getting messages out to a certain number of people. It then turned into more of an opportunity to address broader, key issues that were coming up that concerned students. Finally, it began to involve both educational and social issues. So, it started off very practical and turned into something quite different. QMR: So, you felt a shift in the topics you have been writing about? AS: Yes, I found that I quite enjoyed the writing experience itself. I like finding

messages in different things that are relevant to medical education, to physicians and professional development. The blogs provided that kind of creative way of getting ideas out there. And I really like the way people can respond and develop an exchange of ideas that help you get the sense of general opinion. I mean some of those posts have had a lot of really thoughtful feedback. To me, it was an eyeopener in terms of its potential of getting things out into the public domain. QMR: I noticed in your recent mentorship article that you start off with Szilard’s influence on Einstein’s letter to President Roosevelt that led to the development of the Manhattan Project. Now this is something that seems unrelated to medicine and you somehow tie it back to medical education. What moved you towards such an approach? AS: I was always intrigued by how that letter came about and how those two people came together to inspire such a significant point in history. I think those kinds of historical events resonate with people in a much more profound way, particularly when they’re wrapped up in human experiences. The fact is that medicine is about human relationships, right? Learning from historical relation-

ships is about understanding the human condition in its various forms and there are all kinds of instances in life which are relevant to what we talk about with patients. QMR: You recently gave a talk on resilience for the wellness day lecture and I noticed that you had been discussing this way back in 2014 in your blogpost. Are there certain themes you find yourself going back to regularly in your writing? AS: Well, there are themes that keep spiraling and resilience is one of them. I read and hear a lot about the concept of resilience and it’s one of those human things that runs through whatever you do. Resilience drives success in all kinds of endeavors. In medicine, we have to deal with obstacles of all kinds and so resiliency becomes very important here. QMR: I understand that writing about your thoughts and reflecting on your experiences helps you deal with stressors and acknowledge the more positive aspects of life. Do you think blogging or journaling should be encouraged in medical students that are being trained, moving forward, just to develop that sense of resiliency?

Interview

SANFILIPPO AS: The idea of thinking about your experiences in a constructive way, taking them apart and learning from them is part of human growth. And it’s easy not to, especially in this day and age, as we are distracted and go through the day without allowing any one sort of moment to stick. The ability to stand by and think about what you’ve been doing and build on it is essential to anybody’s growth, and particularly to a physician’s growth. When I first read about the concept of reviewing adversity experiences – I realized that the good doctors have been doing it forever. Osler’s whole learning experience was about examining cases and examining failures and successes – taking them apart and learning from each of them a nugget of what led to it. In today’s world, I think we’ve got to do it deliberately as there is too much focus away from this. I love the idea of building on experiences in whatever ways you can do it, and writing and blogging for me is a very deliberate way to do it. It can force you to dive into a magazine article or newspaper article or hear about something that’s going on. It is really intriguing to find a lesson in it, pull that nugget out and learn from it, although it’s easy not to and you can get mentally lazy. Blogging, like journaling is a way of forcing you to self-reflect. QMR: Do you schedule time in your calendar for blogging or is it something that happens when notable things come up in your experiences or in world events? AS: Generally, I do an article once every two weeks. I usually have a list of ideas that I keep in a book – it has around 1520 ideas now. I don’t have to force ideas, as most of them sort of come up naturally through experience. I begin to formulate

ideas in open moments during the day, but I don’t put pen to paper until the weekend of the deadline. My deadline every couple of weeks is Monday morning, so I get up early on Saturday and Sunday, which is a quiet time when family isn’t up yet, and I take an hour and put my ideas down over a cup of coffee. I actually love that time and look forward to it, so blogging for me has been something that I don’t have to force.

“Thinking about your experiences in a constructive way, taking them apart and learning from them is part of human growth” QMR: You said that you have a certain list of ideas you want to blog about, but what motivates you to pick one topic over the other? AS: My target is medical students, so when I put together a blog, the audience that I am really trying to reach are medical students. I look at things that would be relevant to their development – it’s not about their academic development, as we have a robust curriculum, but what I think about a lot is them learning how to become happy and content physicians, satisfied in their career. This is not a lot different than professional development, but it has its different parts, so I will read

a lot and keep track of world news the best I can. Although that is not easy to do, things will come up that just make me realize that there’s an opportunity. One of my patients, whom I had known for a lot of years, passed away a while ago, and her last conversation with me was significant so I thought I would take bits of that and make it into a blog – something for the future. There are issues around how physicians and patients interact, and how physicians deal with patient loss – you know physicians grieve, but it’s a different kind of thing so I thought that would be a useful topic for students to hear. I also read about Bloom’s Taxonomy recently, which is a theory of how people learn, and I realized that it has particular application to medical education so that is something I might talk about in the future too. I have general ideas like these that I keep track of. I like to start with a story – it’s mostly about storytelling here. So, if I can tell a compelling story that is interesting in itself and extract the nugget from it, I think that’s a very effective way of teaching, using metaphors. QMR: I think that’s what keeps the attention of the reader as well – rather than just telling them what it is, they figure out what it is and that’s more meaningful. AS: Absolutely. People will understand it with reference to their own experience. If it has reference to something that they can grasp and something that is natural to them, and then turn it around to say “okay, lets look at it this way” – that is quite powerful. QMR: Going back to the topic of narratives of medicine, I found a Masters program in narrative medicine in a lot of places in the US, Columbia Universi-

for instance. They say that narrative medicine uses people’s stories as ways to promote healing. What are your thoughts about having such programs available to medical students or professionals? AS: I’m all for it! In fact, a lot of what we do in medicine is involving narrative. Whenever you go to a medical conference, you’ll find that one of the most well-attended sessions are not state of the art. Regardless of the specialty, what always attracts attention are whenever physicians are presenting their challenging cases that taught them something that caused them to come to new realizations – the so called “my toughest case”. So, there is a huge role for narratives. In fact, you learn through narrative in a lot of cultures, especially when they don’t have written language and they pass on their history and wisdom through stories and allegories – not just the content, but its delivery. There’s a bonding that happens just through one person exchanging some insight with another, about an experience or story. QMR: You said that you started blogging about 4 years ago. Did you or have you ever kept some sort of journaling record along with it as well. AS: I kept a journal years ago, but I had trouble keeping up with it and I realized that I was just logging the events of the day and that wasn’t really what was important to me. These articles that I’m doing go deeper, into the significance of those events. QMR: Right, and I think it may be hard to pull out significant things everyday. Then it becomes more of a chore, just something to get out of the way. AS: Definitely, and this two-week cycle

kind of works for me because when I do have some time to think about things, it’s usually with reference to the theme that I’m working on at the time. I’ll throw it around and maybe bounce it off some friends and let it come together. After I construct the ideas mentally and have a structure in mind, I’ll work on them. My wife, Michelle is my editor. She’s really good at knowing what I’m trying to say and letting me know if I’ve hit the mark. She will make some suggestions about punctuation or what fits better where, and I’ll do some shifting and fine-tuning before I come up with a final product.

“There’s a bonding that happens just through one person exchanging insight with another, about an experience or a story”

think the ability to electronically maintain ideas has a huge advantage in terms of the storage and the ability to move things around. What matters is that folks use whatever medium they feel most comfortable with and closest to. I mean, there are a lot of writers who dictate and never even really type. I was reading a story of folks who write manually because that was the only thing available to them, and there are writers who have one finger typing, and those who use electronics as a way to dictate – I don’t think it matters. I think whatever works for the individual is best, but one thing I would say is the use of language can be influenced by how you put ideas down and there’s a certain discipline in writing with pen and paper because you have to put your sentences and paragraphs together in a way that makes sense. There’s a discipline that needs to be maintained in terms of putting the sentences together that says what you want to say, so that someone can pick up and understand a nugget of what you’re trying to express. I worry that some of the ways that folks are expressing themselves is very quick and efficient, but it isn’t transferable and it’s not going to stick, because the discipline must be there.

QMR: Shifting gears a bit, it seems like technology has made it easier to journal or blog by making it possible to share the very act of journaling with others and making typing more efficient than just writing things down. However, do you think typing has the same effect as writing things down?

QMR: Going back to the audience for your blogs, I noticed that a lot of the comments on the articles have been from your colleagues. However, I was wondering if your patients know about your blog and if so, does it interest them in terms of knowing how the current, or the next batch of physicians are being trained?

AS: That’s a good question. A few years ago, I would have said no. I would have said that there’s something intrinsically intimate about putting pen to paper, making those scratches, correcting and going back, but I’m not so sure now. I

AS: Well, I know some of them do, because they make comments about it to me. The blog exists on our site and it gets pushed out each week to a certain crowd, so it is easy for our medical students and staff to access the blog. But for

Interview

AS cont’d: the patients, they would have to go looking for it to find it. I do know that some of them do because they told me, but I have no idea beyond that. One weird thing about blogging is not knowing where it’s going – you don’t know who is digging it up, so it truly is publishing in a sense because it is open to the world. There is a tool with which I can tell how many times it has been picked up, but I can’t tell who, other than if people choose to respond online or tell me about it.

takes the sort of sensitivity to situations, willingness to share, and discipline to put it into a form that people can then digest. When they do it, physicians can be very effective communicators and story tellers, but there is nothing in our training that provides that opportunity. I mean, it would have to be something that we take on as personal interest because, if anything, our training moves us away from that ability to express, write and publish. One of my brothers is a lawyer, and we

QMR: For the patients that said they have read it, what sort of impression or comments did the they have to make?

“Whatever the medium, whether it be music or arwork or writing, sharing creative ideas is about expressing the human experience and learning from it and coming to grips with it”

AS: The few who made comments have told me that they found it interesting and surprising that their doctor was writing about such things. I think it makes them see their physicians in a more human kind of way and see them as more of a person, which is a good thing. They have not expressed any strong feelings about what I have said – but based on their comments, I think they have enjoyed the idea that their doctors might be thinking about things other than medicine. QMR: Speaking from a more general perspective, there have been a lot of physician authors that have come into the light over recent years. What are your thoughts about physicians being involved in literature? AS: Whatever the medium, whether it is music or artwork or writing, sharing creative ideas is about expressing the human experience and learning from it and coming to grips with it. I think physicians have a particular insight into the human experience based on their experience with patients who are going through such difficult points in their life, so I definitely think physicians have something to contribute. For it to all come together, it

talk a lot about different societal issues. I learned that we have very different ways of approaching issues, and part of it is the reason he went into law and I went into medicine. Also, our training has made us think about things differently and no one is wrong – they’re different, but complementary and mutually valuable. QMR: Yes, that’s very interesting. We talked about the benefits of blogging for you as a writer or distributor of these forms of writing and we touched upon the potential benefit it may have for our

patients. Do you think your blogging has influenced your peers in any way? AS: I think I raised topics that they might not have thought about otherwise, so I have given them an excuse or motivation to think about something in an unusual way. Whether it has materially changed what they do or how they think, I don’t know. I think we all influence each other in different ways every time we chat; we don’t realize it and I hope these are positive influences. We have to get past the idea that something is influential only if it results in a big change – things don’t work that way; they nudge. So, I think I have made some nudges, but I have no idea how much. I have folks mention that they’ve read something or what they thought about it or just thank me for writing it, but I have no idea on the negative side. QMR: You said that you keep your blogs every two weeks, and I noticed that there are some entries from other students and staff in between those weeks. Is that something they come to you with? And if any student is interested in contributing an article to your blog, how do they go about it? AS: Theresa Suart is sort of the unofficial editor of my blog. We coordinate the content, so I do it every other week or sometimes I do two in a row – it really depends on my schedule. She coordinates the other weeks too, and it’s a combination of folks around the office or faculty, or sometimes students. We try to work it in such a way that there’s always something new each week. I am happy to have students do articles, and they can contact Theresa if there is any interesting content they wish to share with our medical school community.