QMR - Volume 11, Issue 2 (2018) by Queen's Medical Review

QMR

QUEENâ€™S MEDICAL REVIEW

DIVERSITY

IN MEDICINE

Table of Contents ISSUE 11.2 DIVERSITY IN MEDICINE Letter from the Editors

Reviews & Reflections Roots & Wings Ashna Asim (Meds ‘20)

Essays & Articles

Diversity of Physician Renumeration Models Sachin Pasricha (Meds ‘20)

Call Me Maybe? A Patient's Perspective of Interprofessionalism in Medicine Shubham Sharma (Meds ‘21)

Ethical Diversity in Medicine Daniel Huang (Meds ‘21)

Unpacking the Backpack Anonymous (Meds)

Genocide and Eugenics Policy in Canada Roya Abdmoulaie (Meds ‘20)

Checking My Privilege Bryan Franco (Meds ‘21)

The History of Queen's Medicine: A Story of Acceptance and Betrayal Andrew Belyea (Meds ‘21)

Book Review of the Issue Maggie Hulbert (Meds ‘20)

Interviews Interview with Dr. Mala Joneja Scott Wakeham (Meds ‘20) Interview with Dr. Andrew Bennett Sara Brade (Meds ‘21)

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

WRITERS & MANAGING EDITORS EDITORS Roya Abdmoulaie Ashna Asim Andrew Belyea Sara Brade Bryan Franco Daniel Huang Maggie Hulbert Sachin Pasricha Shubham Sharma Scott Wakeham

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, We are excited to present Issue 11.2: Diversity in Medicine. A lot of hard work went into this issue and we are very proud of the results. As a student-run publication, QMR always strives to serve as a platform to student voices, exploring a variety of perspectives and starting meaningful discussions. We hope this issue in particular gives a glimpse into some of the ways we can understand diversity within the field of medicine. Diversity can have a lot of different meanings, and there are a variety of ways to examine the topic. Through commentaries, interviews, creative pieces, and essays, this issue explores different ways in which medicine does, should, and can improve upon engaging in diversity. The issue begins with Scott Wakeham’s (2020) interview with Dr. Mala Joneja about her insights as Director of Diversity and Inclusion, followed by Sachin Pasricha’s (2020) examination of the Diversity of Physician Remuneration Models and their impact on patient care. An introspective piece, Roots and Wings by Ashna Asim (2020), speaks to the importance of diversity in identity and details the work she is doing in a group designed to empower young women of colour in the Kingston community. Next, Shubham Sharma (2021) explores the complexities of the interdisciplinary healthcare system in Call Me, Maybe? A Patient Perspective of Interprofessionalism in Medicine. In the anonymous dialogue Unpacking the Backpack, students take a deeper look at the potential symbolic meanings behind the medical school backpacks and examine its impact in the medical profession. Following this, Sara Brade (2021) conducts a wonderful interview with Fr. Deacon Andrew Bennett, exploring the intersection of religious freedom and the Canadian healthcare system. In Ethical Diversity in Medicine, Daniel Huang (2021) examines the implications of conscientious objection, particularly in the cases of MAID and abortion provision. In Checking My Privilege, Bryan Franco (2021) reflects on how we understand our place in society, and the impact of privilege on creating that place. Then a poignant piece, Genocide and Eugenics Policy in Canada by Roya Abdmoulaie (2020), discusses the historical and contemporary impact of forced sterilization of Indigenous women. Andrew Belyea explores diversity in Queen’s Medicine’s history in his article The History of Queen’s Medicine: A Story of Acceptance and Betrayal. Finally, in our book of the issue, Maggie Hulbert (2020) reviews Redefining Realness: A Memoir by Janet Mock, which examines Mock’s experience as a trans woman, activist, and advocate, and details her navigation through the medical system. As always, we would like to thank all of our extraordinary staff. Without our writers, editors, managing editors, and layout team, none of this would be possible. Thanks to our amazing graphic designers Hassan Hazari (2020) and Martina Heinelt (2021) for all the artwork featured in this issue. Issue 11.2 is sure to be a thoughtful, reflective examination of diversity and how it relates to all of us involved in the medical field in terms of our practice, our patients, our system, and ourselves as individuals. We hope you enjoy 11:2 Diversity in Medicine as much as we do!

Edrea Khong & Chantal Valiquette Editors-in-Chief 2017-2018

INTERVIEW WITH DR MALA JONEJA Scott Wakeham, Meds ‘20

Dr. Mala Joneja, Associate Professor of Medicine and Director of Diversity and Inclusion, took time out of her busy schedule to chat with Scott Wakeham (Meds '20) about her role and her thoughts/experience with regards to inclusion and equity. QMR: Can you briefly describe your role as Director of Diversity and Inclusion? MJ: My role is the Director of Diversity and Equity for the School of Medicine. This position requires me to assist leaders, faculty and students in addressing diversity and equity in the school. I was asked at a recent accreditation review to summarize in one word what diversity and equity means in the school of medicine and I chose the word ‘inclusion’. My overarching goal is that the School of Medicine be an inclusive place to teach and learn, and that diversity and equity are promoted in all areas of the school. My responsibilities include identifying areas of priority, reviewing policies and statements related to diversity, establishing linkages with groups and working with the University on issues of diversity and equity. QMR: What do you enjoy about this position?

MJ: This position has a very noble mission, and one of social justice. I believe that it is in fact the school of medicine ‘doing the right thing’. I am honoured and humbled when I am given the opportunity to hear faculty, students and leaders tell me about the challenges they face related to promoting diversity and inclusion. QMR: What do you find challenging about this position? MJ: I am going to be completely honest with you. It is challenging to repeatedly hear about exclusion and discrimination. However, I acknowledge that this is necessary, and every story makes me see the potential to move forward to create a positive change. QMR: Where do you find the inspiration and motivation to continue tackling these issues day to day? MJ: I receive a great deal of support from the leaders in education here (Dean, ViceDean, Undergrad Dean and Dept Chair) and that is heartening. More recently, I encouraged my department chair, Dr. Stephen Archer, to read “We Should All Be Feminists” by Chimamanda Ngozi Adichie. He reflected on this, and other experiences of inclusion and equality, in a recent blog post titled “The Accidental Feminist”. I can also see the values of inclusion and equity in my day-to-day interactions, whether it is an idealistic medical student with a new idea for the curriculum, or a colleague who refused to let an incident of racial discrimination go unreported. The people around me motivate me.

QMR: What previous experiences have informed the way you view the importance of inclusion? MJ: I would be lying if I told you that my own experiences of discrimination have not informed my view of inclusion as a priority. However, two other factors have contributed to my views and my approaches to issues of diversity. During my fellowship training and first year of practice, I completed a Master of Education degree at OISE/U of T. What I learned from OISE was that educators, students and the educational institutions have the ability to promote positive change. I was taught that education is transformation, which I truly believe. As a professional school with prestige, the School of Medicine has an opportunity to be a leader in promoting inclusion and positive change. The second factor is an opportunity that was given to me shortly after I arrived at Queen’s University. For four years I was the director of International Medical Graduate (IMG) programs and I was a resource for IMG residents and the faculty supporting them. Watching the IMG residents try to assimilate to the Canadian medical education culture, I observed how the medical education and teaching hospital cultures reacted to people who were different. I saw some resistance but also compassion and flexibility. QMR: What changes have you seen within the Queen’s community during your time as director? MJ: For the school of medicine, inclusion is now a priority. Things are starting to happen. For example we have a recruiter for Indigenous medical students and an

Interview

outreach program for high school students in North Kingston. More information about the School of Medicine’s priorities can be found in the Diversity and Equity statement: http://meds. queensu.ca/academics/undergraduate/policies-committees/diversity-equity-statement

ed leaders in an important position for change. Allies are those who support people from marginalized populations and work to better the environment and have a better opportunity. A great resource for more information on this can be located here: https://medicine.utoronto.ca/allyship-and-inclusion-faculty-medicine

Another change I have seen is that there now exists a more open and honest discussion around issues of race, gender and discrimination. In my opinion, this is a very positive step and crucial in promoting diversity and inclusion, even though such discussions can be difficult.

"My overarching goal is that the School of Medicine be an inclusive place to teach and learn"

QMR: What do you believe to be the area where Queen’s UGME/SOM has the greatest opportunity for growth, in regards to Diversity and Inclusion? MJ: Personally, I see three priorities for areas of growth within the School of Medicine. These would be: 1.To continue discussions around importance of diversity at various levels, namely in policy and curriculum development and revision. 2.To continue listening and having these conversations. I have to give a shout out to students. Medical students have amazing ideas about diversity and inclusion and should be encouraged to discuss in both preclerkship and during their time in the teaching hospital. Faculty should listen to students, because students have a very unique and contemporary point of view. 3.Development of allies. We are a prestigious medical school with well-respect-

QMR: How can medical students positively contribute to inclusive spaces, both in the classroom and with patients? MJ: You can be allies - understanding and supporting each other. Strive to make your teaching and learning environment one where everyone feels safe, and no one feels threatened or diminished. Sharing experiences can be beneficial. I personally love to meet with students who are willing to share their experiences and/ or ideas. Please send me an email if you would like to meet and share either. I am consistently impressed and interested in students’ perspectives and innovative ideas. QMR: What do you think faculty can do to positively contribute to these spaces as well?

MJ: Faculty are in an excellent position to model inclusiveness and also become allies. My message to faculty and leaders: if you have not experienced exclusion or discrimination yourself, then put yourself in the shoes of someone who has. Imagine being denied a learning or career opportunity simply because of the way you look or sound. Imagine being excluded from contributing to the work you are passionate about because of who you are. With this empathy and understanding, people can become allies. QMR: Recently, Dr. Sanfilippo published a blog post about the balance of freedom of speech versus avoiding offense. He argues that potentially the pendulum has swung too far in favour of avoiding offense, and that we may be suppressing healthy and vigorous debate. What are your thoughts on this matter? MJ: The problem here is that both of these options are the easy way out. It takes compassion and understanding to be able to avoid offense and have debate. It can be uncomfortable to do this, but discussion and understanding can occur independent of offense or debate. It’s uncomfortable, and perhaps this is why people don’t always consider it an option. There was a hashtag that came out of Edmonton called “#makeitawkward” in confronting racism and sexism. We have to be brave enough to deal with this awkwardness and we have to be able to talk about it in a way that is calm and compassionate to move forward. These principles actually align with professionalism: to have respect and compassion for people within our medical role.

Essay

DIVERSITY OF PHYSICIAN RENUMERATION MODELS Sachin Pasricha, Meds ‘20 When one utters the word “diversity”, the first type that comes to my mind is racial, followed by socioeconomic status. Many aspects of diversity are highly discussed and engaged within medical school - race, socioeconomic status, gender, sexuality, and geographic, among others. All naturally fall under the umbrella of the social determinants of health. While we identify how the diversity in these social determinants affects patient health and the delivery of care, we rarely acknowledge economic determinants, which too can have a profound impact on the delivery of care. More specifically, models for physician remuneration are diverse, and each provides unique incentives and disincentives, all of which can directly and indirectly affect the care we provide. There are three ways family physicians can be paid in Ontario. Paying family physicians is analogous to purchasing chips at a vending machine, where patients consume chips, the government pays for the chips, and physicians are the vending machines themselves who ought to be paid. Payment can be based on the number bags of chips consumed (a fee-for-service model), the number of patients who are provided chips (a capitation model), or a set amount (a salary). The first is a fee-for-service model, whereby clinicians get paid a fixed amount for each service they provide a patient. One benefit of this system is that physicians get paid for exactly what they do. Thus, they are motivated to “work hard”. That being said, with different services allotted varying dollar amounts, such as a full physical exam or a routine pap smear, certain services are incentivized over others. If counselling and other preventative measures are attached to a smaller dollar value, these important services may be performed less. Moreover, while a fee-for-service model encourages physicians to “work hard”, it can also promote overtreatment, a common issue in modern medicine. Certain unnecessary diagnostic tests may get performed because of the financial incentive for doing so. Alternatively, unnecessary prescriptions may even be written. After all, it is quicker to write a prescription and move onto the next patient, than spend time explaining what lifestyle modifications should be tried prior to that prescription. With

Vending Machine A, the physician gets paid by the bag of chips, and is thus incentivized to provide people with more chips (i.e. overtreatment).

"When it comes to economic determinants, notably renumeration models, we shy away from discussion out of fear of being labelled mal-intentioned or moneyminded" In a capitation payment scheme, physicians are paid a set annual amount per patient they enrol in their practice. The philosophy is that physicians will realize that providing effective and comprehensive care is in their best interest. Why? Well, because by treating patients effectively, these patients will visit the doctor less, and the doctor can therein enrol more patients. While logical in theory, issues do arise. Though prohibited, this system may promote physicians to engage in unofficial, perhaps even unintentional, patient selection. The elderly, sick, and those with chronic disease may find it more difficult to find a physician due to how physicians get paid the same for treating them as compared to a young healthy lad. Naturally, the young healthy lad would visit the physician less than the 78-year old man with heart disease, kidney disease, dementia, and diabetes. These non-enrolled patients may then find it difficult to gain access to any services due to how the system is capitation-based, not fee-for-service based. Newer blended capitation payment schemes have attempted to alleviate such issues by adjusting the payment per individual by age and gender, and providing fee-for-service payments for non-enrolled patients. However, these systems remain imperfect and

such a system may still promote patient discrimination, since age and gender are not the only determinants of how often one visits their physician. WithVending Machine B, physicians get paid by the number of people consuming the chips, not the amount of chips consumed, and physicians are thus incentivized to choose consumers who eat fewer chips (i.e. patient selection).

essential. Cognisance of the unintended effects of each scheme will enable well-intentioned physicians, which likely includes all of us, to provide more balanced and effective patient care. That means the next time they accept a patient into their practice, they will stop, and think: is the model in which I am being paid influencing my decision to provide this service or treat this particular patient?

A salary-based method of compensation is a third model. Providing physicians with a set annual income prevents the aforementioned issues of patient selection (present in capitation models), and overtreatment (present in fee-for-service models). However, another issue arises â€“ the prospect of under-treatment. Because physicians are not paid more for each service or for each patient, this system in the absence of minimum requirements could dis-incentivize physicians from enrolling more patients, and providing more services. At Vending Machine C, where the government pays by the vending machine, not the number of people or bags of chips, physicians are dis-incentivized from re-stocking vending machine merchandise (i.e. under-treatment).

Often in medical schools, we are keen to discuss the social determinants of health. We recognize that being able to appreciate these determinants will deter us from our subconscious biases, and enable more comprehensive care. However, when it comes to economic determinants, notably remuneration models, we shy away from discussion out of fear of being labelled mal-intentioned or money-minded. However, this fear only makes us more likely to fall victim to the issues associated with each remuneration model.

The biggest issues facing the fee-for-service, capitation, and salary remuneration models are overtreatment, patient selection, and under-treatment, respectively. These problems stem from a physicianâ€™s unofficial ability to choose patients, and to choose what chips (i.e. services) to provide each patient with (enabling over and under-treatment). While we emphasize these as problems and issues, they are more appropriately categorized as potential problems and issues. Both the mal- and well-intentioned physicians can propagate such potential issues, the former of which is for obvious reasons. However, when paralleled with a lack of cognisance, even well-intentioned physicians, which the overwhelming majority of physicians are, can inadvertently fall victim of such issues. After all, physicians are human and while they may not intentionally over-prescribe, their subconscious may promote this behaviour. That is why being consciously aware of the diversity of physician remuneration schemes remains

The facts are simple and the message is clear. Remuneration models are diverse, and admittedly more complex than is described here. Each model comes with unintended effects that can negatively impact patient care. To avoid these effects, it is beneficial for us to learn about and actively discuss the diversity of remuneration models. References 1.University of Ottawa: Society, the Individual, and Medicine. Alternative Methods of Payment of MDs and Hospitals: Impact on Patterns of Practice. http://www.med.uottawa.ca/sim/data/ md_payment_e.htm. Last updated: August 7, 2015. Accessed: January 12, 2018. 2.Ontario Ministry of Health and Long-Term Care. Primary Care Payment Models in Ontario. http://www.health.gov. on.ca/en/pro/programs/pcpm/. Accessed: January 12, 2018. 3. Ugurhan Berkok. Queenâ€™s University Healthcare Economics 243 Course Content.

Reflection

ROOTS & WINGS Ashna Asim, Meds ‘20

Identity is a complex concept, but in simplest terms it can be thought of as processual, or ongoing. Most often, identity is formulated through an individual’s identification with others – such as with family members and friends, or cultural and national groups. With outside influences shaping consciousness, constructing one’s ‘authentic’ identity is difficult – especially in a hegemonic society in which the norm or accepted mode of being is cited consciously and unconsciously as whiteness. Racism can have a deep impact on identity because one’s identity becomes marked onto one’s skin. This marking – or epidermalization – suggests that identity does not solely lie in the consciousness. Instead, one’s sense of self is also related to body image; we map our ‘self ’ onto our bodies so that consciousness is projected onto our bodies. Moreover, body image can become distorted and negatively coded. Thus, racism deforms how one sees oneself because, as according to Fanon, an individual cannot map one’s identity if it is interrupted by racialization (Fanon, "The Fact of Blackness”). When an individual is racialized and only knows oneself through the eyes of another, the individual experiences alienation. This is how an individual is made into the “Other.” Conscious of what it feels to be the Other, I was excited to have the opportunity to get involved with Roots and Wings, a newly formed community organization and Working Group of OPIRG-Kingston. Roots and Wings creates a space and community for girls of color (aged 8-12) in Kingston. For young girls of color growing up in a predominantly white Kingston, the process of mapping their identities is difficult. Their experiences of racism and discrimination can be isolating and can have a negative impact on the way they construct their identities regarding their race. In light of this, Roots and Wings create a space that is not only aware of their racial identities but is accepting and encouraging of their growing into these identities. The girls learn about teaching and sharing skills, social justice issues, connecting with communities of resistance, activism, and advocacy. The goal of the Roots and Wings is to create a space in Kingston for young girls of colour in which they can share their experiences, form

friendships, celebrate their identities, and learn about different ways in which they can make positive contributions to their communities. My involvement with Roots and Wings is to co-facilitate biweekly workshops and activities as a “troupe leader.” My fellow troupe leaders and I run workshops on topics such as body image, race and racism, environmental issues, indigenous issues, and food security. During these workshops, girls work towards building skills and knowledge through theme based units and will earn badges (like Girl Guides) when they accomplish learning goals and act and/or connect with the community. Our hope is to empower young girls of colour in Kingston. We hope that our girls celebrate their identities. We hope that we can give them skills to be empowered and empower others. Ultimately, our goal is that these girls become leaders in the community and continue to strive towards creating a just and equitable society.

CALL ME, MAYBE? A PAT I E N T ' S P E R S P E C T I V E O F I N T E R P R O F E S S I O N A L I S M I N M E D I C I N E Shubham Sharma, Meds ‘21 “Hold on a second – I’ll transfer your call.” This was the seventh time I had heard that message within a span of 10 minutes. Lucky number 7? I hoped to myself as I was getting tired of having to give an elevator pitch to everyone who picked up the phone – someone part of an assembly line in place to help me, the patient. No, assembly line isn’t the right expression as it suggests some sort of linearity – something new is added at every step to get closer to the final product. I wasn’t really sure if I was even getting anywhere. “Hello, how may I help you?” A gentle voice greeted me. Here it goes again, I thought to myself as I began my elevator pitch for hopefully, the last time. “Seems like you are going to have to start over from the beginning – I’m going to transfer you to the secretary of your referring physician.” Noooooooooooo, I shrieked internally, feeling as if I had reached the final level of a game and lost, without saving it, meaning that I am going to have to go through it all over again. While I waited for the secretary to pick up, I thought to myself that it isn’t all too bad – I didn’t end up exactly in the same place. I learned which questions I really need to ask at the beginning so as to not go down the exact path. Yes, this wasn’t linear, but it wasn’t completely circular either. Seems more like the spiral learning curriculum I keep hearing about. That ended up being a long thought as I kept hearing the phone ring from my side…waiting…until it finally went to voicemail. Guess that’s the end of the road, I thought as I left a voicemail. The healthcare system can be related to cogwheels turning together, its many parts working in unison. Medicine is no longer a profession of an individual know-it-all and gone are the days when patients were okay being out of the loop and trusted their physician to make decisions. Medicine has moved towards a more patient-centered approach, at the same time as it has become more diverse. But that comes with the onus on the system to make it easier for patients to follow their own care.

Interprofessionalism in healthcare doesn’t just mean transfer of care between general practitioners and specialists, but also involves a whole web of non-medical professionals. It isn’t just doctors, residents and nurses, but also secretaries, receptionists and technicians – everyone plays a role to ensure that the patient can smoothly and systematically navigate the healthcare system. The importance of this notion of interprofessionalism became abundantly clear to me when I dislocated my ankle the first month back from my first winter break of medical school. I was well-aware of the diversity in medical professionals through my many observerships, but I didn’t see the larger picture of diversity in healthcare until I had to navigate the system myself. I interacted with paramedics, clerks, residents, emergency room physicians, physiotherapists and ultimately an orthopedic surgeon, while receiving care for my acute injury, but all these interactions were very brief and immediate because of the urgent need for care. Surprisingly for me, the person I talked to the most while trying to access care was the orthopedic surgeon’s secretary, and the ever-changing operator of the switch board, who greeted me regularly before transferring all my calls.

"The person who I talked to the most while trying to access care was the orthopaedic surgeon's secretary, and the ever- changing operator of the switch board" As a modern-day patient, it isn’t enough for me when the doctor simply says that an MRI will be done within two weeks, because as a modern-day medical student, I realize that once the doctor sends my referral, I fall under the jurisdiction of diagnostic imaging, who may have their own timeline. This was reinforced by the fact that I had to navigate the maze to find out what was happening with my MRI – as I was told to wait for a call, which hadn’t come in a week since my appointment. It took me calling and talking to over half a dozen different pieces of the healthcare puzzle before I understood where the MRI requisition was sent and a few more calls after that to learn that I would need to wait 6-8 weeks for an appointment.

Review

Reflection

Again, I had to figure out on my own that there is something known as a “cancellation list”, which I put myself on and thankfully, got an MRI scheduled a month sooner than I would have otherwise. I would have preferred to have been informed of these options before I left the clinic in the first place, or at least been followed-up with before being put on a long regular waiting list. As a patient, my priority was to get access to care as soon as possible – because although the physician’s job was done after he saw me and moved onto the next patient, my life was temporarily halted, and I needed to know when I could start getting back to it. The growth of interprofessionalism in healthcare serves the potential to provide fast, directed and effective care to patients, but with the increasing number of handovers from professional to professional, the paranoid mind cannot help but be afraid of falling through the cracks. Queen’s does an excellent job of exposing students to the different professionals that work under the healthcare umbrella – through Interprofessional Shadowing and the First Patient Program. These programs give us the opportunity to acknowledge that medicine is more than just physicians and that patients spend a significant amount of time interacting with non-medical professionals and waiting for answers. It is important to understand the difficulties that patients face so we, as healthcare professionals, can do our job and advocate for them. Sometimes, experience is the best teacher, and my experience as a patient trying to access care has informed my understanding of patient care and how it feels to be in the unknown. If we cannot provide answers, the least we can do is ensure that patients know where they are in the process and how to navigate through the sea of professionals that make up the healthcare system.

UNPACKING THE BACKPACK a roundtable discussion by Anonymous Contributors, Meds Introduction: When I was in elementary school, backto-school shopping was my favourite time of year. Staples - or rather, The Business Depot, as it was known back then - was the home of every Crayola colour marker I could imagine. The good Business Depots even had the scented ones. With my head in the clouds, I would trail behind my mother, asking her at every aisle if we could get whatever newfound shiny item I had somehow picked up - only to be met with disappointment, most of the time. And then - we would reach the backpack aisle, with backpacks that had all of my favourite characters on TV printed across their fronts. And though I knew my mother would never get me the 101 Dalmatians backpack, because my Cinderella one from last year was still in pretty good shape, I always begged. I would tell her that I had never wanted something that bad, ever. And she would smile sympathetically, hold my hand, and lead me away. Years later, I idolized another backpack. A backpack printed in fluorescent colours, that even my elementary school self probably wouldn’t have found attractive. Except this one couldn’t be purchased at The Business Depot. It had to be earned. And I felt the same way that I had felt, all those years ago. I had never wanted something that bad, ever. And now here I am, another few years later, looking down at my brand new, garishly blue, shiny backpack. I thought, in that moment, that I would feel proud of myself - as if all of my accomplish-

ments - all of my hours of studying, and of trying to be good enough, or to be seen as good enough - would suddenly feel like it had all paid off. But the thing is, it didn’t. So I did some talking with my peers, and I asked them a question that I was almost afraid to ask, for fear that I was looking too far into it. After all, it was just a backpack, for crying out loud. So I asked: “What does the backpack mean to you? O: I’ll be honest with you, I didn’t think too much about it other than...thank goodness I don’t have to apply again, because this is a symbol that I’ve gone through the hardest part of becoming a physician, getting into medical school. Naive, I know. But after a few months, I started to feel very uncomfortable walking around with the backpack. It struck me that the backpack is a symbol of conformity and homogeneity amongst medical students. As beautiful as it is to think that we are “all in this together” and that the backpacks symbolize exactly that, it is also a disconcerting. M: Being in medical school, and identifying as a “med student” has been such a quandary for me. When I was in undergrad, and then grad school, I felt so many confusing, negative emotions whenever I would see the latest OMA backpack colour and the students wearing them. They served as a reminder of what I had not yet accomplished, and often felt I would never be able to accomplish. What took me a long time to recognize was that the backpack is a symbol, in some ways more meaningful

to the people who could see them than to those wearing them. So much of my desire to pursue medicine was tangled up in other people’s expectations of me. I think this is true, in so many important ways, for many of my peers. We spend a lot of time maintaining this weird notion of independent thought and effort in med school. That the reason why we are successful is because we worked hard and made decisions entirely on our own, as if that somehow validates our arrival in medical school. That our family and friend’s expectations and hopes for us, not to mention their efforts and sacrifice and support, have nothing to do with why we are here. All of which is to say that all of my fantasies of finally having the OMA backpack featured other people. In these fantasies, I showed it to my parents, taking pride in their pride, that finally I have this symbolic, ugly thing that objectively announces: I made it, I’m finally in medicine. A: The “finally making it” definitely resonates with me, and I think it is, in some ways, a part of my identity that I am honoured to have made mine. My concern, however, is in the fact that it becomes so easy for others to identify us. An identification that breeds a lot of assumptions about where I come from and who I am. What unsettles me the most is that the backpack tells the world that I am a Medical Student. The same as every other Medical Student with the blue backpack. In so many ways, the backpack represents privilege - a fluorescent declaration to the world that I am a medical student who is smart - a Chosen One, of sorts. The backpack tells the world that I

Review

deserve respect from those who don’t know me. That I deserve to be noticed. And of course, all of that is silly - I deserve none of those things. The backpack is such an incomplete identifier because it ignores all of the other dimensions of my identity apart from Medical Student - and it fails to tell the story of my privilege in my journey to becoming a medical student. O: Definitely. In many ways, the backpack is a homogenizing symbol - one that relabels our diverse personalities into a single identifier. But at the same time, there is a gross homogeneity in medicine as well; the profession in and of itself it not particularly diverse and tends to overselect people from certain backgrounds and qualifications. A lot of medical students come from privileged backgrounds (and I know that this term can be scary for people to use because of the inherent discomfort of being born with certain traits or things that make certain other things easier for you, but I think that privilege is to be acknowledged). For example, many of us have physicians in the family, which privileges us because it gives us the support we need to pursue medicine - both in terms of tangible resources, like financial support for MCAT courses or the expensive medical school application process, as well as psychosocial, in terms of providing mentorship and greater insight into the personal challenges and joys of practicing medicine. A: And so, when many students come from similar backgrounds, and share similar personality traits of being high-achieving, studious, and determined, it creates a natural homogeneity in the class. It

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becomes very easy to label and to clump students to become a group of people - a single entity - instead of recognizing the uniqueness of individual differences. And then, to some degree, there’s the hidden curriculum of medical school itself - so somewhere between the application process, training, and practice, physicians become very, very similar people. And the backpack just seems to me a tangible symbol of this somewhat-acknowledged fact that that we are the same - or becoming the same - and there’s an acceptance that we should be the same. M: When I accepted my offer, one of the first things I did was denounce was the backpack. Hilariously, my parents, the people I was denouncing it to, didn’t even know what it was. I had to explain that first before letting them know that I was never going to wear it. And of course, I spent the first week here wearing it, because it turns out that it’s a really strong backpack that can hold all of my heavy school things. But I spent the first month feeling really displaced, and the backpack somehow contributed to this sense of losing myself. I stopped wearing it, and stopped trying to feel comfortable with this new identity that I felt was being assigned to me. Instead, I’ve spent the last few months trying to be less uncomfortable. Part of it has been tied to the backpack, yes. I have a difficult time with conformity (uniformity?), and wearing that backpack in a sea of our peers has made me, at times, feel as lost as Nemo. A: I think we also need to acknowledge, though, that the medical student identity transcends the backpack. There are so

many other ways in which I have had to fight to keep my sense of self, that the backpack, while still relevant, has taken a back seat. Some days, it returns with a vengeance - who I am seen as, who I feel myself to be, all consumed by this image of myself trudging to school, wearing a bright blue beacon on my back. And on other days, it’s just the only bag that can fit my laptop, lunch, dinner, pencil case, clinical skills clothing and gym stuff all at once. And maybe it’s a personal choice - how we choose to see it. Do we let the backpack define us, or do we define for ourselves who we’re going to be, even when we’re wearing our backpacks and could easily just fit in? O: I think we can also see the backpack as a means of empowerment - not necessarily an item of definition, but a tool at our disposal. It is (in some ways) a demonstration that we are in this together, and that when things get tough, we only have to look for another backpack to find a familiar and friendly face. It has the ability to help us identify others within the same field and relate, bond and form connections with future physicians. But the off-target effect is that it also alienates us as a group of individuals and we suddenly assume a lot of responsibility when we are so readily identified. When you do something great, it reflects on all of us, but when you do something bad, it also reflects on all of us. So perhaps the issue isn’t that medical school makes us a homogenous group - but that society as a whole does. In which case, perhaps it’s better to be able to band together and find community in one another.

UNPACKING THE BACKPACK A: That being said, I think it’s important then to fight for the uniqueness in our individual identities, as future members of the medical profession. I have actually found it very refreshing that so many students in our class come from different educational and occupational backgrounds. Before I started med school, I thought med students were all the same - the same pre-med undergrad degree, the same research jobs and hospital volunteering. But maybe that’s a product of the fact that we don’t celebrate difference, instead glorifying the prototypical pre-med as the ideal medical school candidate. Medicine is full of diversity, but I find that it isn’t cultivated or specifically encouraged, and that oftentimes it’s up to us as students to maintain it, and continue to discover who we are as people. M: And loss of identity is so easy in face of the overwhelming nature of medical school. There’s so much to do that you don’t feel like you have time to do things that make you unique. Like how am I supposed to stay on top of my work, participate in extracurriculars, sleep 8 hours a night, eat proper food, exercise, call my mom on the phone, wash my hair, and still find time to do things that make me, me? O: I feel that. In addition to the pressures of daily life, there is also a pressure to form meaningful relationships. Especially at the beginning of the year, when you haven’t met very many people or made very many friends, there is an immense pressure to conform - for fear of being lonely. And this, perhaps, is the first step in losing oneself. We spend so much of

our day-to-day lives with one another, that it’s almost impossible to emerge fully unaffected. Perhaps we don’t want to, either - perhaps medical school is the place to be vulnerable and to learn from one another, while still being ourselves. M: Medicine is this strange black hole. At the beginning of the year, I used to sit in class breaks and just read political discourse and articles about art. It was my method of keeping connected and abreast of issues important to me that weren’t being addressed in our curriculum. I saw it as a form of rebellion. But as the semester progressed, I found it harder to do. I didn’t have time to read, I also needed to study. And make friends. And deal with this new city and university that felt so unfamiliar and unfriendly so much of the time. And I needed to maintain connections with the people who until I got to medical school, helped make me, me. We are at the mercy of so much in medical school that sometimes I feel like we are in a very purposeful factory, because there is no other way that we could ostensibly do the things expected of us at the end of all this. And that’s terrifying. We’re part of an institution that suppresses our identities, in order to form this version of ourselves that can live, survive and thrive in medicine. A: Simultaneous forces of conformity and self doubt make it confusing because you are told that you need to be a certain way in order to succeed (like, get good marks on tests or interact with patients a certain way) and that fuels a bunch of self doubt that then makes you feel guilty for doing anything other than school

work. You feel like you need to study all the time because everyone else is doing better and you feel like your presence here is a mistake (imposter syndrome at its finest), which then makes you lose yourself even more and makes you doubt yourself even more and even when you do end up doing well in school, it’s devastating because you’ve totally lost yourself. It is a cycle. O: Speaking to that, we’re even told that there is a certain manner of conduct in order to be considered a professional (like, there is a process to building rapport with a patient) and it just feels so sterile. It’s like you can’t integrate your personality into these interactions because the way you conduct yourself — if it’s not in a very poised manner — can be interpreted as being unprofessional. I had this moment earlier this year where people I considered mentors offered a critique on my method of patient encounter based on my personality. I was told that I am too bubbly and that it could interfere with me being seen as professional when I enter into a patient encounter. In a completely different scenario, I was told (by complete strangers) to stay the way I am because I would make a fantastic doctor that they would appreciate having. This experience in itself showed me how much the medical system wants you to project yourself in a certain manner, like there is one interpretation on what being professional is. I’ve been questioning who I am as a person ever since, whether or not I truly belong here and how much of the critique I should take to heart and change about my patient encounters so that I am taken seriously. But making

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those changes would ultimately change how I interact with people and who I am. I’ve been told by others that the best doctors they have had are those with unique personalities, with whom they have been able to interact with and feel like who they are talking to is also human. This all makes me think that maybe by the virtue of learning the “how tos” of interacting with patients we are also taking away a part of our personalities that makes our version of human interaction unique. I understand that there needs to be a structure, and a layer of professionalism but it cannot be at the expense of who we are. M: What I have come to realize is that maintaining a sense of self in medicine requires conscious effort. I’ve made a goal to specifically make time to do the things I love, regardless of anything else

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I should be doing at the time. There will always be things that you should be doing (like studying, assignments, practicing for clinical skills) but the one method of maintaining my personal well-being is by disregarding all those things for a few hours within the week to do what I love. Following this discussion, I went home and gave my backpack a long, critical look. In the end, I realized that remaining unique, but remaining a part of a whole in medicine requires work and balance that only you yourself can maintain. I guess all-in-all there is no real right or wrong way to interpret the homogeneity within this profession. On one hand, it provides us the ability to provide a certain standard of care that is common across the board, and having the similarity is like a uniform- a definition of who we are

as a profession- what we do and it helps people understand that so they know what to expect when they encounter different physicians. It also provides a sense of comfort- a knowledge that wherever you are there are others who will always understand you. Where it becomes a problem is when the homogeneity takes away from the intrinsic diversity within us- our interests, our personalities- how we present ourselves to the world and at the start of our journey as medical students I think it is important to remain cognizant of this uniformity and make a choice as to how you want to proceed. It is up to us to be critical of what we are learning and who we are becoming and decide what aspects of what make us unique are worth our conscious time.

INTERVIEW WITH DR ANDREW BENNETT R E L I G I O U S F R E E D O M A N D H E A LT H C A R E

Sara Brade, Meds ‘21

I had the privilege of speaking with the Rev. Dr. Andrew P.W. Bennett about the nature of religious freedom in Canada and its intersection with healthcare. Fr. Deacon Andrew is a Ukrainian Greek-Catholic deacon of the Eparchy (Diocese) of Toronto and Eastern Canada. Fr. Deacon Andrew serves as Programme Director of Cardus Law at Cardus, Canada’s faith-based think-tank. Cardus Law looks at the role of law in society and the nature of our citizenship with a particular focus on religious freedom and the role of public faith in Canada. He also serves as Senior Fellow at the Religious Freedom Institute in Washington, DC. Fr. Deacon Andrew previously served in the Canadian foreign service as Canada's first Ambassador for Religious Freedom and Head of the Office of Religious Freedom from 2013 to 2016 during which time he led in defending and championing religious freedom internationally as a core element of Canada's principled foreign policy. He remains a regular and active commentator on religious freedom in Canada and abroad. Fr. Deacon Andrew’s ambassadorial appointment was the culmination of a 14-year career in the Canadian civil service. He holds a B.A. Hons. in History (Dalhousie), an M.A. in History (McGill), and a Ph.D. in Politics (Edinburgh). . QMR: What drew you to a career devoted to defending religious freedom? What is the most difficult aspect of your work and what do enjoy the most about your work? AB: Growing up I always had interests in history, in theology, and in questions of belief even from being a young boy. At different points in my academic formation, I kept returning to questions of religious belief, how they were manifested at different points in history, questions of people’s conscience, how they exercised their conscience to seek to do justice, to seek to do what was right, and to seek to advance a common good. I would say that certainly the Ambassador role was a fulfillment of many different aspects of my formation and then the role that I am taking on now with both Cardus, which is Canada’s only faith-based think-tank, and also with the Religious Freedom Institute down in Washington, DC, is a continuation of that development in my vocation. In terms of what the most difficult aspect

of my work would be, I would say it is education – it is educating people about what religious freedom is, why it is important, and correcting an “amnesia” in our society around just what is religious faith. We, through Cardus, did some wonderful research with the Angus Reid Institute this past year showing that 60% of Canadians have some connection with a religious tradition. They might not be going to church or to temple or to mosque or synagogue every week but they have a connection with a religious tradition. In the work that I am doing now one of the biggest challenges is educating people in government, people in the professions, and the secular elites that we have in our country that religious freedom is important because first, the majority of Canadians have a connection with a religious tradition; but second, there is something within us as human beings, a metaphysical need we have to understand, to contemplate, to ponder the following questions: Who am I? Who am I in relationship to others? Who am I in relationship to the world in which I live – the society in which I participate?

Who am I in relationship to God if I have a theistic belief? Or, who am I in relationship to a particular philosophy to which I choose to ascribe? I think it is very important to try to correct this “amnesia” in our society at present and to focus on why religious freedom is so important – why it is important for fostering a deep pluralism. What do I enjoy the most about my work? It is the same thing – I like educating people, I like engaging with people, I like speaking with people of different beliefs, people of no religious belief, to talk about why this is so important. Religious freedom, freedom of conscience, is at the heart of our democracy because it speaks to this need to respect one another – not tolerate – to tolerate is very easy; but, to respect means to seek to understand the other person and to respect one another for our different beliefs and to ensure that in this very diverse country in which we live we can actually build a common life together. We might fundamentally disagree with something that a person believes but we still have to see that per

Interview

son as a human being and we have to respect their human dignity. QMR: What does it mean to protect religious freedom? How is religious freedom tied into fostering a truly diverse society? Do religious ideas belong in public discourse? AB: If I don’t have the freedom to think and to exercise my deeply held beliefs, how then do I possibly move on to other fundamental freedoms such as, freedom of expression, freedom of assembly, or freedom of association. The first freedom is freedom of religion or conscience and it speaks to thought, contemplation, and reflection, which are essential elements of who we are as human beings. The other freedoms that link on to freedom of religion or conscience are action-oriented. When I express myself, I am expressing my beliefs, speaking of my beliefs, writing about my beliefs, engaging with others about my beliefs. Now, I think we have to be very clear about the origin of these freedoms. These freedoms are not the gift of society to us and they are not given to us by the state or by government; rather, they are freedoms that we bear simply by being human beings. These freedoms are inherent in what it means to be a human. In that sense, religious freedom is tied into fostering a pluralist society. Diversity is a fact – Canada is a diverse country – that is just a demographic fact that people have different belief systems, different religions, different ideologies, different experiences, and different national or ethnic backgrounds. This diversity is something that makes Canada a wonderful country – a

wonderful community of individuals. In contrast, pluralism is a context; pluralism is a way of living that diversity. In advancing religious freedom, we are trying to recognize that we need to have a deep and profound pluralism. That pluralism is where we respect one another and respect difference. We can respect

"If I don’t have the freedom to think and to exercise my deeply held beliefs, how then do I possibly move on to other fundamental freedoms such as, freedom of expression, freedom of assembly, or freedom of association?" that people are going to have profoundly different beliefs that we might fundamentally reject, but we still have to see in that person a human being who bears a certain dignity. Again, those fundamental freedoms are linked to that understanding of human dignity. If we want to have a deep pluralism, we cannot seek to proscribe certain beliefs. Now, we have to be careful that there are reasonable limits to

freedoms. People cannot act physically violent toward other people and have to respect the laws of the land insofar as they are just and that the laws that we have in this country do not violate the moral law and do not violate the fundamental freedom of conscience. Do religious ideas belong in the public discourse? Absolutely. We have for a long time in Canada bought in to and accepted wrongly a post-Enlightenment myth that religion is a private matter or that religion is something you do at home. That view is not historically accurate nor theologically accurate from many different faith perspectives. In no religious tradition that I can think of does the individual live that faith alone – you live it in community with others. In living that in community with others, you are called to live that faith publically – necessarily. Now, if we want to have a deeply pluralist society, we have to allow for religious beliefs to be present in the public square because that enriches our common life and our public debate. People can bring ideas that are drawn from deep wells of religious tradition – traditions that go beyond the “zeitgeist” and draw upon thousands of years of thought about these questions that are important to us as human beings and to our society. Those ideas need to be present in the public square so that we can engage them and so that we can engage one another. In democracy, there is always going to be a tension between opposing views and there is going to be a tension within debates; but, to argue that a particular debate is over or a particular debate has been solved, I do not think that is very pluralistic or democratic.

INTERVIEW WITH DR ANDREW BENNETT R E L I G I O U S F R E E D O M A N D H E A LT H C A R E

QMR: What do you see as the most pressing threat(s) to religious freedom in Canadian society today or on the horizon? AB: In Canada, and in most liberal democracies, we are fortunate and blessed to not have severe constraints upon what we believe or what we seek to exercise in terms of our religious beliefs. I think we should be glad that we have a liberal democracy, but we are not perfect and what I see as some of the most pressing threats to religious freedom in Canada are related to this “amnesia” I spoke of before – a lack of awareness about what religious freedom is and a fear that, perhaps, if we grant people too full a freedom of religion or conscience it will constrain the rights of other people. I think that is an unfounded fear because all of us have the ability to exercise freedom of religion – whether we are religious or whether we are non-religious. Embedded within freedom of religion is the freedom not to have religious belief. We also have to be careful not to politicize religious freedom; this is not an issue of the partisan right or the left; it is not an issue for Conservatives or Liberals. This is an issue for humanity; this is an issue that relates to our living out our common life together. The government increasingly appears to be trying to compel belief. For example, the Canada Summer Jobs program issue that has cropped up in recent weeks where the government has said to different groups that if you want to hire summer students and take advantage of this Canada Summer Jobs fund to support those internships, you must attest to say

that the core mandate of your organization supports the freedoms and rights within the Canadian Charter of Human Rights and Freedoms and what they call “underlying values” that relate to women’s reproductive rights, including access to abortion. Firstly, there is no right to access abortions enumerated in the Charter – it is not there. Secondly, a lot of Canadians, particularly people of faith, are being forced into a position where if they want to access this particular program, if they want to apply to this particular program, they’re being told, you must subscribe to these values if you want to access a tax-payer funded program. What the government is doing in that case is compelling belief – saying to those people that you have to reject the beliefs that you hold if you are, for example, a Christian organization, an Orthodox Jewish organization, or an Islamic organization, in order to be able to access these funds. Instead of the criteria solely being related to different criteria that are pertinent to employing summer students, they add on what is essentially a “values test” or a “religious test” and that is a violation of the fundamental freedoms that we hold. Now, some people would argue that you can have those fundamental freedoms but you can only exercise them in certain ways. In other words, you can only exercise them so long as you agree to these values. That is, again, a constraint on belief. What about someone who perhaps has an organization that does not have a mandate that relates to any of these issues and they themselves are not a particularly religious person. It could be a small construction company that every summer hires 10 students to

help build homes. The government is now saying to the person who runs that company who maybe has no interest in entering into these debates, “If you want to be able to access these funds, through this application, you must declare your opinion.” What if they do not want to declare their opinion? The government is, again, compelling belief.

"We also have to be careful not to politicize religious freedom; this is not an issue of the partisan right or the left; it is not an issue for Conservatives or Liberals. This is an issue for humanity; this is an issue that relates to our living out our common life together" QMR: Today (Wednesday, January 31, 2018), will be an interesting day for religious freedom in the Ontario Superior Court is ruling on whether or not the CPSO can force physicians objecting to assisted suicide to provide an “effective referral” for patients requesting assisted suicide. In medical school, we are taught to lay our “personal biases” we aside to provide patient-centred care. Some argue that physicians must perform or refer for treatments that they

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object to, on the grounds of conscience or religious beliefs, in order to provide the care a patient is requesting. Is this an infringement on the religious freedom of physicians? What impact do you think the outcome of this case will have on religious freedom in Canada?

values, that contradict religious values, that they are not bringing their biases into their professional lives – again, it is nonsensical. Secular values are not neutral in the same way that religious values are not neutral – they make certain claims and they state certain beliefs.

AB: I think the decision in the case will be a significant milestone in current debates over religious freedom in Canada and I would anticipate that it might not be the last word on this particular case – it could go up to the Supreme Court as these cases tend to.

"Secular values are not neutral in the same way that religious values are not neutral – they make certain claims and they state certain beliefs"

There are a number of issues at hand here. First, what is the nature of patient-centred care? I think Hippocratic medicine speaks to what patient-centred care is and at the core of Hippocratic medicine is “do no harm.” I think there is a need to come back to a Hippocratic understanding of medicine in our present day and age. I am not a medical doctor; but, as someone who accesses medical services, I would desire to have a physician who is grounded in Hippocratic medicine and has freedom of conscience. The idea that we can lay aside our personal biases in the work that we are called to do, whether we are doctors, lawyers, or fuel the work for think tanks, is nonsense. You cannot lay aside your personal biases. We are human beings – we are body, mind, and spirit. You cannot just have a box in your front hall to deposit your beliefs as you leave the house every morning to go off to practice medicine or practice law or whatever and then come back and open the box and there they are perfectly preserved and unsullied by contact with the public square. That is nonsensical. To say that some that hold certain secular

An effective referral is simply moving the moral responsibility for that action by one degree. The person who provides an effective referral still has a particular moral responsibility because they know eventually what that effective referral will lead to. In that sense, an effective referral is forcing the doctor with certain conscience rights to violate those rights. What is important to note is that there are many patients in this country who value doctors that have a similar understanding to themselves about what is compassionate care, what is conscience, and they want to be able to access those doctors because they can trust them. I think there has to be choice in medicine and the flexibility to ensure that medical professionals, along with any other professionals, can exercise their conscience freely. Also, I do not think doctors are simply civil servants. Doctors are not there to serve the state or particular reg-

ulatory bodies; doctors are there to serve patients. We need to be watching these decisions that will come out of the courts. I will not comment on a particular specific case in this way, but we need to watch what comes out and we need to be vocal in ensuring that conscience rights are protected. I think one of the worst things that could happen would be to close various professions to people that hold deeply religious beliefs – whether you are a Catholic, an Orthodox Jew, a Muslim, or other. We need to have that diversity within the professions because it should reflect the deep pluralism that we have in our society. QMR: Do you have any suggestions for how my classmates and I, as future physicians, can work to uphold and enhance true diversity and religious freedom in the medical profession for our future patients, for Canada, and for the world? AB: Remember that you yourselves have consciences and remember that you yourselves have beliefs. These beliefs are necessarily going to inform how you practice medicine – the idea that you can just clinically slice those off with a scalpel and put them aside is nonsensical. There is a desire for compassionate care. Patients, I think, want their doctors to understand them, to understand their needs, to understand their beliefs and they want them respected. For physicians to understand diversity and to respect pluralism is also to be cognizant of your own humanity and to understand what it means to be a human being: body, mind, and spirit.

ETHICAL DIVERSITY Daniel Huang, Meds ‘21 Towards the end of the Barry Smith symposium this past year, I remember the panel and the audience started discussing the controversial issue of conscientious objection to medical assistance in dying (MAID). In the course of this discussion, many important questions were raised: How might conscientious objection impact patients’ access to MAID? How should we punish or protect conscientious objectors? And more broadly, should a doctor’s personal ethical beliefs–their conscience–have a place in our public healthcare system? The debate surrounding conscientious objection to MAID has, by in large, been confined to the realm of law and bioethics. At the point of care, professional bodies and individual organizations have devised policies that have so far managed to balance physicians’ freedom of conscience with patients’ access to care.1 According to David Campbell, clinical ethicist at KGH, the practice in Kingston is to have a “referral service”, where attending physicians who are unwilling to provide MAID notify the chief of staff and a MAID working group, and the group then directs the patient requesting MAID to a list of willing providers. Elsewhere however, medical conscientious objection has had far greater con-

sequences. In Italy over 70% of gynecologists refuse to perform abortions (3). As la Reppublica reported in 2013, it is common to see hospitals across the country with cardboard signs taped outside their doors declaring, “Here, there are no longer voluntary abortions” (4). A precipitous rise in illegal abortions–estimates suggest over 20,000 are performed annually– suggests that patients are quickly losing access to safe and professional reproductive care (5). Udo Schuklenk, a professor of bioethics at Queen’s University who has written extensively on conscientious objection in medicine, argues that situations like this show that conscientious objection “is nothing more than condoning unprofessional conduct by people who have a monopoly on these services.” While the scale of the issue might differ in Italy, for him the practice of conscientious objection here in Canada is equally problematic: “Conscientious objection is symptomatic of doctors who lied when they took their oath, when they said that ‘my patient comes first’, because what they are saying is that ‘I always come first.’” Proponents of conscientious objection, on the other hand, argue that the ability to refuse to perform morally dubious acts is crucial for maintaining a medical practitioner’s moral integrity (6). And, it’s

hardly a unique privilege of the medical profession. Conscientious objection in medicine is borrowed from a similar tradition in the military where religious and secular pacifists could avoid conscription by proving that they held sincere anti-war beliefs. As Dr. Schuklenk acknowledges, it was important in this case for pacifists to be given this right because it would be “a threat to the integrity of these people as moral agents” if they were forced to fight. “We wouldn’t want them to suffer that sort of moral distress.”

"Should a doctor's personal ethical beliefs their conscience - have a place in our public healthcare system? " The idea of moral distress brought me back to that evening at the Barry Smith symposium. During the discussion, one clerk volunteered to share a recent case where his patient was refused MAID. Halfway through, he had to stop. He was overwhelmed with emotion recounting the suffering and pain that he saw his patient endure as the devastating rejec-

1. Of course, these policies inspire their own important debates. In Ontario for instance, some have argued that requiring conscientious objectors to refer MAID candidates to a willing provider, as stipulated by provincial legislation, forces physicians to be complicit in what they consider to be an act of killing, which hardly protects their conscience. Another flashpoint is the ongoing debate over the right of entire institutions to opt out of MAID services (1). Advocates of MAID argue there should not be an institutional right to conscience because it creates a significant barrier for patients trying to access MAID, forcing them to transfer institutions and causing delays and unnecessary suffering. One such institution, the Misericordia hospital in Winnipeg, was recently accused of delaying the transfer of one of its MAID candidates, an 88-year-old man suffering from ALS (2).

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IN MEDICINE tion was delivered. was delivered. It was a vivid reminder that so many decisions in medicine, including supporting or rejecting MAID, arise from the provider’s deepest belief about what it means to harm or heal. To be forced to act against that belief, as inadvertently happened with the clerk and his patient, is to cause moral distress as visceral as forcing a pacifist to fight in a war. And, as defenders of conscientious objection point out, the residual effects of this distress–emotional exhaustion, reduced competency, and eventually indifference to their job–ultimately affects the patient’s care. Far from being a dereliction of duty, physicians who conscientiously object are protecting their moral integrity and their relationship with their patients. However, for Schuklenk this ability to act on one’s personal moral beliefs, and in doing so force the patient to bear the consequences, is deeply unprofessional. “What is expected of doctors is uniform professional conduct. That’s the end. The moment they bring their unique ethical compass into practice”, like their beliefs about MAID or abortion, “their service provision becomes a lottery.” For him, and other opponents of conscientious objection, the practice is a dangerous conflation of personal opinion and pro-

fessional obligation, two realms that should be separated as soon as the doctor enters his or her office.2

"For Schuklenk, this ability to act on one's personal moral beliefs beliefs, and in doing so force the patient to bear the consequences, is deeply unprofessional" Moreover, as Schuklenk points out, “nobody forced doctors to become doctors.” So, while conscientious objection was the only way for pacifists to avoid conscription, doctors who don’t want to perform MAID today have another option: choose a different career. Says Schuklenk, “If you are a gynecologist, and abortion is part of the deal, there is no reason to become a gynecologist if you don’t want to provide abortions.”3 Conscientious objectors in the military were also re-

quired to perform alternative services for the military, and historically were even punished with jail time. Doctors today continue to be “perfectly happy to take the privileges of their monopoly, which includes societal standing, respect, [and] a fairly high salary.” Finally, conscientious objectors in the military needed to take a ‘sincerity test’ to determine how deeply held their beliefs were. Those who failed the test were refused their request for conscientious objection. No such test exists for physician conscientious objectors today (8). In light of these issues, some have suggested that conscientious objection in medicine can be made more palatable by following the military’s lead (9). One could imagine a conscientious objection tribunal set up by professional colleges that tests for the sincerity of a conscientious objector’s beliefs, screens for invidious discrimination, and imposes alternative services like requiring the objector to help cover the workload of physicians who are willing to perform MAID. Perhaps these will alleviate issues of access, weed out insincere or discriminatory objectors, and create a durable mechanism to weigh a physician’s conscience and their professional duties.

2. Some bioethicists also point out that acting on individual conscience may in some cases be more than just unprofessional, but downright discriminatory. As Thomas Hobbes writes in The Leviathan, “For a man’s conscience and his judgment is the same thing; and as the judgment, so also the conscience may be erroneous” (7).

3. This raises the issue of doctors who are currently in practice. It would seem unreasonable to expect these doctors to have chosen a different career, as at the time of choosing to enter medical school they could not have reasonably expected that MAID would become legal practice. Here, Schuklenk makes an analogy with teachers, “distance education was not on the agenda when I joined the [teaching] profession, and I have strong objections to it… but of course I have to do it because, hint, over decades professions change, everywhere.”

ETHICAL DIVERSITY However, even in a world without thistribunal, where issues of sincerity and moral distress and patient access remain unresolved, advocates for conscientious objection argue that there must still be a place for conscientious objection. Like Schuklenk, they believe the right of conscientious objection hinges on the concept of professional duty.

quest a feeding tube. Studies show this might actually not be a very good idea, especially for reasons of quality of life… At the end of the day, the attending has to decide, ‘Am I going to offer it or not?’” Campbell himself counsels physicians in this case to “stick to their guns” and refuse their patient’s request.

As Campbell explains, “Traditionally, physicians have always had the right to conscientious objection because of the nature of healthcare. It’s an ethical and moral enterprise and you want physicians who are moral individuals because they are making very important moral decisions.” Therefore, “there is a unique responsibility to the community and to individual patients [for doctors] to… have very strong moral radars.”

As Campbell explains, 'Traditionally, physicians have always had the right to conscientious objection because of the nature of healthcare. It's an ethical and moral enterprise and you want physicians who are moral individuals'

In other words, a physician’s professional duty to their patient is not simply to provide adequate access to legal medical services, no questions asked, but rather to have a strong ethical framework–a strong conscience–to best navigate all the ethical issues that arise in the course of their patients’ care. As Campbell points out, “They’re not just technicians, they’re complex ethical issues that arise in the course of their patients’ care. And that means sometimes, when a patient’s requests misalign with the physician’s judgment about what is in the patient’s best interest, the physician should be able to overrule the patient. A hypothetical case, Campbell illustrates, is “where you’ve got an elderly, demented patient who’s not eating, and the family of the patient says, ‘no they have to eat,’ and they re-

But, why should an ethically oriented profession lead to diverse ethical beliefs among its individual practitioners, one where a minority can fundamentally disagree about a clinically sound practice like MAID? Presumably books like Doing Right exist to teach medical students and practitioners a common ethical framework to follow. Perhaps this diversity is a natural consequence of our pluralistic society and the diverse backgrounds of individuals who enter the medical profession. As Campbell says, “We’re a diverse

society, so anyone who wants to become a doctor, if they’re able, should be allowed to become a doctor.” For many in the bioethics community, this diversity is also a necessary safeguard against collective hubris (10). We should give freedom to individuals to follow their conscience because we can never be sure that the decisions that society makes as a whole, like with MAID or abortion, are ultimately the ethical ones. Indeed, there are many historical examples of ‘normal’ medical practices that would be considered objectionable today–the eugenics movement, medical experimentation on human subjects, medically justified racial discrimination, etc. Today, we laud the conscientious objectors of the past who refused to perform those heinous acts. How can we be so sure our future selves won’t also be lauding today’s conscientious objectors? For Schuklenk on the other hand, the limit to our tolerance of ethical diversity and that limit should in fact be the practice of conscientious objection, particularly in the case of MAID. As he observes, there is a clear difference between the kind of diversity in decision-making that Campbell describes in his hypothetical case and the diversity that leads to conscientious objection to MAID. While one is rooted in clinical judgment, the other is clearly not. After all, doctors would only be using conscientious objection as a method to refuse MAID if the patient had alreadymet all the eligibility criteria to recieve MAID as set forth by the law; criteria

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IN MEDICINE which take into account the clinical necessity of MAID for the patient4. In other words, a conscientious objector is not only acting against the patient's request, but also the clinical indication of the case. For Schuklenk, “above all else, we must value the interests of the patient… Physicians are service providers. Don’t

delude yourself about that. It’s a specialized service, but it’s a service no different to other services that people provide.” So should the practice of conscientious objection be the limit to ethical diversity in medicine? I clearly don’t know. But, the question itself raises an uncomfortable

thought. From Campbell: “We talk a lot about diversity…but we don’t really know what that means. And, when we’re really conflicted with really challenging cultural issues, those are incredibly difficult and complex. How do we navigate those? There is no clear answer.”

References

1. Durland, S. L. (2011, 2011/08/). The case against institutional conscience. Notre Dame Law Review, 86, 1655-1686 2. Caruk, H., & Hoye, B. (2017, October 26). Waiting to die: Winnipeg man says faith-based hospital delayed access to assisted death. Retrieved February 6, 2018, from CBC Manitoba website: http://www.cbc.ca/news/canada/manitoba/misericordia-assisted-dying-maid-1.4371796 3. Minerva, F. (2015). Conscientious objection in Italy. J Med Ethics, 41(2), 170-173. doi: 10.1136/medethics-2013-101656 4. De Luca, M. N. (2013, May 23). 194, Così sta morendo una legge. In Italia torna l'aborto clandestino [So law 194 is dying. In Italy clandestine abortion returns]. La Repubblica, Inchieste. 5. Sala, I. M. (2017, November 14). Abortion in Italy, a right wronged. The International New York Times, Opinion. 6. Wicclair, M. R. (2011). Conscientious objection in health care: An ethical analysis. Cambridge: Cambridge University Press. 7. Feldman, K. S. (2001). Conscience and the Concealment of Metaphor in Hobbes's Leviathan. Philosophy & Rhetoric 34(1), 21-37. Penn State University Press. Retrieved February 6, 2018, from Project MUSE database. 8. Kantymir, L., & McLeod, C. (2014). Justification for Conscience Exemptions in Health Care. Bioethics, 28(1), 16-23. doi: 10.1111/ bioe.12055 9. Clarke, S. (2017). Conscientious objection in healthcare, referral and the military analogy. J Med Ethics, 43(4), 218-221. doi: 10.1136/ medethics-2016-103777 10. Sulmasy, D. P. (2008). What is conscience and why is respect for it so important? Theoretical Medicine and Bioethics, 29(3), 135-149. doi: 10.1007/s11017-008-9072-2 11. Medical assistance in dying [Fact sheet]. (2018, January 8). Retrieved February 7, 2018, from Health Canada website: https://www. canada.ca/en/health-canada/services/medical-assistance-dying.html#a2

4. For instance, one element of the eligibility criteria is to have a “grievous and irremediable medical condition.” This, in turn is defined

as: 1. Having a serious illness, disease or disability, 2. Being in an advanced state of decline that cannot be reversed, 3. Experiencing unbearable physical or mental suffering from your illness, disease, disability or state of decline that cannot be relieved under conditions that you consider acceptable, and 4. Being at a point where your natural death has become reasonably foreseeable (11).

Reflection

CHECKING MY PRIVILEGE Bryan Franco, Meds ‘21

“I'm not on the outside looking in, I'm not on the inside looking out. I'm in the dead fucking center, looking around” rapped Kendrick Lamar (2011) in his debut album. My friends and I nodded our heads, partly in appreciation for the beat and partly in agreement with the lyrics. In high school, it was our nightly ritual to meet after work. We spent countless nights smoking, playing cee-lo, and arguing about hip-hop albums that were just released – paying no mind to the fact that we were each expected in school the next morning. School had no appeal because stories told by rappers were closer to our reality than any story ever told in school. My perspective radically shifted in medical school when the same issues rapped about in hip-hop, such as socioeconomic status and community housing, became important in my professional development. Social determinants of health are increasingly integrated into the medical curriculum (Sharma, Pinto, & Kumagai, 2018). The explicit assumption is that future physicians’ knowledge of disparities will lead to better care for vulnerable patients and ultimately, professionals motivated to reduce inequities. I argue that an unspoken but important underpinning for this education is to train physicians that are able to “check their privilege” – especially as the Canadian medical workforce struggles with its lack of diversity (Young et al., 2012).

would preclude having to live from paycheque to paycheque. A future that involved improving the human condition was unheard of because we were too focused on improving our own living conditions. I am fortunate to have had the “capacity to aspire” to medical school (Southgate, Kelly, & Symonds, 2015). Enough pieces somehow fell into place that allowed me to recognize that improving my condition and those of others do not have to be mutually exclusive. I suspect it had to do with being welcomed into the most compassionate homes that struggled to keep the lights on. Or maybe because my mom worked three jobs, so I kept myself occupied by watching hours of Discovery Channel during the summers which piqued an interest in science. Perhaps it was due to teachers that, despite my tendency to be a frustrating student, refused to give up. The only thing that I can be certain about is that my blood, sweat, and tears only played minor roles in me being able to write this article. From mundanely subtle to obviously influential, many factors coalesced to allow us to pursue medicine. Our own privilege is a perpetual window into understanding that the same factors impact each of our patients. Looking through this window leads us to the realization that only slight and mostly uncontrollable differences in circumstances separate us as medical professionals from anyone else.

“Checking privilege” is a contentious concept, with some arguing that it devalues personal effort and struggle (Bovy, 2014). However, I propose that it is a useful tool in medicine – arguably one of the most privileged professions. After all, the society that affords us the privilege to pursue medicine is the same society that perpetuates the inequities that impact our patients.

References

I think about others like me that related more to hip-hop than school when thinking of my privilege. As a teenager, I often delved into fervent discussions about the future with my friends. Most of us came from households where making a livelihood was the foremost priority. Making a living was the only template for our aspirations so we imagined a future as rappers, cooks, mechanics, and anything else that we thought

4. Southgate, E., Kelly, B. J., & Symonds, I. M. (2015). Disadvantage and the 'capacity to aspire' to medical school. Medical Education, 49(1), 73-83. doi:10.1111/medu.12540

1. Bovy, P. M. (2014). Checking Privilege Checking. The Atlantic. Retrieved from https://www.theatlantic.com/politics/archive/2014/05/check-your-check-your-privilege/361898/ 2. Lamar, K. (2011). Ab-Soul's Outro. On Section.80. Top Dawg Entertainment. 3. Sharma, M., Pinto, A. D., & Kumagai, A. K. (2018). Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere? Acad Med, 93(1), 25-30. doi:10.1097/ACM.0000000000001689

5. Young, M. E., Razack, S., Hanson, M. D., Slade, S., Varpio, L., Dore, K. L., & McKnight, D. (2012). Calling for a broader conceptualization of diversity: surface and deep diversity in four Canadian medical schools. Acad Med, 87(11), 1501-1510. doi:10.1097/ACM.0b013e31826daf74

GENOCIDE AND EUGENICS Roya Abdmoulaie, Meds ‘20 Disclosures: I am a non-Indigenous settler. Queen’s University is situated on traditional Anishinabek and Haudenosaunee Lands. The sterilization of those classified as undesirable by Canadian society is one of the more shameful—and secretive— injustices committed by our physicians and government. Sterilization is an umbrella term for the many operations (vasectomy, hysterectomy, salpingectomy, tubal ligation, etc.) that serve to cause infertility. Inspired by the rise of the eugenics movement in Europe in the early 1900’s, lawmakers, physicians, first-wave feminists, and upper-and-middle-class Canadians believed that sterilization was the answer to the evils of society— evils which stemmed from of the poor, the mentally “infirm”, prostitutes, and non-Anglo-Saxon people. While immigrants from Eastern Europe were the primary targets of the earliest eugenics programs, these programs quickly changed to target orphans and those with physical and intellectual disabilities, and eventually to Canada’s Indigenous population. Surviving records indicate that over time Indigenous women became primary targets, and were disproportionally affected by eugenic dogma and practices in Canada (interestingly, this was at the same time upper-class Anglo-Saxon women were targeted in “positive eugenics” programs, in hopes to increase the “ideal” population). Eugenic sterilization was lawful in Alberta and British Columbia. Alberta’s

Sexual Sterilization Act was in place from 1928-1972, though some reports indicate that sterilizations continued even until the early 1980’s. Records from this period indicate that 4,739 sterilizations were approved to be performed, and women, youth, and Indigenous people were overrepresented in these cases. In British Columbia, similar legislature permitted sterilization without patient consent between 1939-1979. There is no way to know exactly how many individuals were affected by this law, as all the records have been “lost”. The basic premise of both these programs were the same: persons deemed mentally unfit by the state were subject to compulsory sterilization, pending approval of The Eugenics Board. Mental ‘fitness’ was determined by IQ testing, which has clear disadvantages when applied to populations that the testing was not designed for. Consider the potential language and cultural barriers impacting one’s IQ score, as well as the impact of residential schooling, such as lower literacy rates than the average population, and an education centered on vocational and religious teachings (which would be unlikely to be examined during an IQ test). Undoubtedly, bias and fabrication played a role in the test results. In some cases, IQ tests were reportedly repeated multiple times to produce low enough scores to subject patients to sterilizations. We know that sterilizations were performed in other parts of the country— including Northern Ontario—by eugenics-minded physicians. These cases were often done coercively with the promise of fertility return. In other cases, women

were told they had undergone an appendectomy in childhood, only to realize later that they had been subject to a sterilization procedure. Even in cases where consent was fully obtained, questions remain around fully informed consent. Were translators made available to women? Where translators were available, anthropological linguistics come into play: was it possible to communicate the permanence of such a procedure, if the concept of surgical sterilization did not exist in a patient’s culture, and had no signifier in her language? It is impossible to know for certain the number of individuals affected by eugenic sterilizations in Ontario and other provinces, as there was no legislation—and consequently, no physician billings—that could be used as records. Unfortunately, research in this area is difficult due to the secretive nature of the procedures. There exists a lack of records (due either to destruction, falsification, or not having been made in the first place), an unwillingness amongst physicians to report having performed these procedures, and an avoidance of research or acknowledgement on the part of the federal government. To illustrate the difficulty in gathering information, let’s consider an example from northern Ontario in the 1970’s. After repeated pressure and shaming from the media and outspoken activists, the federal government launched an inquiry into the sterilization rates in northern communities. This inquiry concluded that 70 Indigenous persons (men and women) from northern communities had been sterilized in the preceding 10

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POLICY IN CANADA years. An independent review later discovered that at least 344 individuals had been sterilized in only 5 years. Perhaps the reasons for this staggering difference could be attributed to different survey techniques, inclusion of different communities, broader definitions of sterilization, and so on. However, many activists and academics cite this as evidence of falsification of numbers and protection of a hidden agenda. Regardless, this example illustrates the difficulty in finding information and research in this area, and the impossibility of knowing how many individuals have been affected. The implications of government-sanctioned, as well as unofficially condoned physician-led eugenic sterilizations, are hugely significant. Such actions constitute genocide, which some Canadians do not recognize as a true and intergenerational consequence of settler’s colonial relationship with Indigenous peoples. These historical offenses may relate to the ongoing devaluation the bodies of women, particularly Indigenous women. One needs only to consider the staggering number of missing and murdered Indigenous women, and the disproportionate rates of abduction and murder between Indigenous and non-Indigenous women (and the blunted law enforcement response to the former) to recognize the continued impact of the abuse, control, and disrespect of these women’s bodies. Awareness of this issue, amongst many others, should inspire settler populations to action, especially following the findings of the historic Truth and Reconciliation Commission. This topic is understandably controversial. Compulsory sterilization is no longer legal in Canada, and is considered biological genocide in the international community. The social, political, and indeed, financial implications of these truths are great. The coercive sterilizations of Indigenous women were an abuse of the fiduciary relationship between doctor and patient, and is one of the many factors

that may contribute to continued mistrust in western medical practices and personnel, and consequently impact patient outcomes. Unfortunately, this issue has not remained one of the past. There are reports even today, that targeted sterilizations of Indigenous women continue in hospitals all over the country, where women are pressured, lied to, and coerced into sterilization by physicians and nurses who have sworn to Do No Harm. Further Reading and Resources: “An Act of Genocide: Colonialism and the Sterilization of Aboriginal Women” Stote, K. 2015 “Canada's Residential Schools: The History, Part 1: Origins to 1939” Truth and Reconciliation Commission of Canada. 2015. “The History, Part 2: 1939 to 2000” Truth and Reconciliation Commission of Canada. 2015. “Leilani Muir versus the philosopher king: Eugenics on trial in Alberta.” Wahlsten, D. Genetica. 1997. “Sterilizing the "Feeble-Minded": Eugenics in Alberta, Canada, 1929-1972” Grekul, J.Krahn, H. Odynak, D. Journal of Historical Sociology. 2004.

THE HISTORY OF QUEEN’S MEDICINE: A Andrew Belyea, Meds ‘21

The story of medicine at Queen’s University is riddled with both triumph and mishaps that simultaneously instill pride and repulsion regarding the school’s history. In a progressively minded world, it is unnerving to learn about systemic sexism and racism that was imparted by the very institution we call home today. Despite this discomfort, it is important to acknowledge and reflect upon this history. It is with this introduction that I welcome you to the story of women and Black med-

ical students at Queen’s University. Before the year 1869, a woman had never studied at Queen’s University. The University had been open since 1841 exclusively to male students. In 1869, the first women were admitted to study specially-designed, women-only English courses at Queen’s. Women were generally accepted by the Queen’s community at first, but continued to face discrimination as noted in an 1876 Queen’s College Journal article:

"We are confident that among people who appreciate the delicate grace and beauty of woman's character too much to expose it to the rude influences, the bitterness and strife of the world, few will be found to advocate her admission to universities."

"Women were generally accepted by the Queen's community at first, but continued to face discrimination" Four years later, in 1880, the first three women were admitted to “the Royal” (the Royal College of Physicians and Surgeons, Kingston, the predecessor of Queen’s Faculty of Medicine). A September 1881 Queen’s College Journal article fondly notes “it is thus gratifying to see the liberal minded action of the Faculty of the Royal College”. One of the first three women admitted to Queen’s to study medicine, Elizabeth Smith, was a tremendous advocate for female physicians. Queen’s had been consulting her while considering medical coeducation, and she keenly posted this announcement in the Globe on July 29, 1879: “Ladies wishing to study medicine in Canada will hear something to their advantage by communicating with Box 31, Winona, P.O.”

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A STORY OF ACCEPTANCE AND BETRAYAL

Unfortunately, many of the initially-welcoming letters she received from promising female students turned to despair as women informed Elizabeth that their families would not provide the same monetary support for them as their male siblings. Nonetheless, two more women were admitted to medicine in 1881; one of them, Margaret Corliss, still holds the record for the oldest admitted Queen’s medical student. She was 44. The unfortunate reality is that women in the Royal would not last beyond 1882. In the two years since their admission, physiology professor Kenneth Fenwick had habitually insulted female students to get a rouse out of the male students. In one notable lecture, Fenwick compared the female larynx to those of apes, which caused the women to storm out of class and file a complaint. In response, Fenwick and 46 male students signed a petition stating they were prepared to leave Queen’s if the women were not expelled, insisting the women were restricting their academic freedom (ironically, Fenwick was one of six men to support the initial decision to allow women into the program at Queen’s). The debate made the front page of the Daily British Whig on 8 December 1882 and was a featured story in the Globe. Elizabeth Smith, now a second-year medical student, expressed her disgust at Dr. Fenwick in her diary the following day: “[Dr. Fenwick] is one of those bland smiling men of external polish who within is black as midnight.”

With much persuasion from male medical students, Queen’s conceded to “abandon the practice of admitting women as long as other medical colleges of Canada were not in full harmony upon the subject.” In other words, until a national consensus could be achieved on women’s position in medical education, Queen’s would reject coeducation.

With much persuasion from male medical students, Queen's conceded to 'abandon the practice of admitting women as long as other medical colleges of Canada were not in full harmony upon the subject' Despite removing women from the program, Queen’s appears to have recognized the value of female medical education, albeit not alongside men. In the following year, 1883, Women’s Medical College at Kingston was founded as a school dedicated solely to female medical education.

Located in the west wing of City Hall, Women’s Medical College in Kingston was the first higher academic institution for women in Canada. Fundraising for the College occurred throughout the year with a welcomed sense of camaraderie which uplifted the medical community following the prior year’s divisiveness. In 1890, with the $4,800 purchase of 75 Union Street, Women’s Medical College moved from City Hall. Generous support continued as donations were made to the College’s new building, including a piano, rocking chairs, and several windows. Kingston was so supportive of female doctors being trained in the city that serious consideration was given to building another hospital exclusively for women and children. The separate hospital never came to fruition. Despite their best efforts, Queen’s University closed Women’s Medical College in 1894 due to a lack of student admissions. Although Kingston had successfully rallied around the College, increasing competition drew female students to study medicine in either Toronto (Toronto Women’s Medical College) or Montreal (University of Bishop’s College). Women were not readmitted to study medicine again at Queen’s until 1943, half a century later. While women fought for their admission to and retention in “the Royal”, Black students were forced out with unprecedented speed.

In 1917, convalescent soldiers returning to Queen’s Military Hospital at Grant Hall refused to be treated by Black medical students. Black medical students had been accepted and welcomed by Kingston’s citizenry for many years, producing doctors who developed practices in Canada, the United States, and the British West Indies. However, as World War I drew to a close, returning soldiers spread anti-Black sentiment throughout the city. In a memorandum prepared by the Dean of Medicine, Dr. James Connell, he voiced his opinion that the best course of action was to remove the students from Queen’s. Both Toronto’s and McGill’s medical faculties were halting the acceptance of Black students, and Connell felt it acceptable for Queen’s to follow suit. Since White hospital patients were adamantly refusing to be seen by Black medical students, Dean Connell felt the students would be better placed in a community with a larger Black population. At the time, the fourth and fifth years of the program were clinical years, and not having a willing patient population was presenting a major problem for Black students. In preparation for their expulsion, Dean Connell had been in touch with Dalhousie University and requested that they accept transferring Black medical students.

to degrade Toronto’s stance of exclusion than reflect inwardly on why Queen’s repeated the mistake. “We would suggest to The Varsity that it look about the halls of its Medical School for negro students, and consult the registrar to see how many are attending at the present session”, the article reads. “Queen’s has had many a coloured student whom she has been proud to graduate, but has found now that she has not the facilities for graduating anymore.”

"As World War I drew to a close, returning soldiers spread anti-Black sentiment throughout the city. In a memorandum prepared by the Dean of Medicine, Dr. James Connell, he voiced his opinion that the best course of action was to remove the students from Queen's"

N.B.: This article has focused on the journeys of women and Black medical students at Queen’s University in large part because these topics have been investigated in relative depth by prior researchers. I do not mean to indicate that other groups have not been ostracized as significantly by Queen’s Medicine, but rather that the available research has focused on these two issues discussed. Furthermore, there has been significantly more coverage about women than Black students, which contributes to a greater allocation of this article towards them. Much of this article’s information has been drawn from A.A. Travill’s phenomenally researched book entitled Medicine at Queen’s, 1854-1920: a peculiarly happy relationship. Additionally, the online Queen’s Encyclopedia proved a valuable resource.

In January 1918, Queen’s expelled all 15 Black students in the Faculty, including those not yet performing clinical work. It is unknown what happened to the expelled students, but it is likely that Dalhousie did admit some of the students. With the University’s continued focus on the war, there is little written about this issue after the students were expelled. In a February 1918 Queen’s Journal piece, more effort was made

N.B.: In recent weeks, following the writing of this article, a historian at Queen’s named Edward Thomas has uncovered deeply held secrets about the history of Black medical students at the University. The details of this work challenge many of the 100-year-old claims mentioned above. His compelling and accurate work, and the ever-changing world of journalism, will be addressed in the next issue of the QMR.

Black students were not permitted to return to Queen’s School of Medicine until 1964. It is evident that Queen’s School of Medicine did not escape the social contexts of history. While today we recognize and acknowledge the mistakes highlighted here, we must consider how far we have come in correcting the wrong for many historically-oppressed groups. Beyond giving ourselves a pat on the back for this, we must push ourselves to question what we continue to do at an individual and school-wide level to perpetuate ignorance and harm to others. We must learn from our very own school’s history to ensure events like these never happen again.

BOOK OF THE ISSUE REDEFINING REALNESS: A MEMOIR BY JANET MOCK Janet Mock, award-winning journalist and transgender activist, has called Redefining Realness her “Trans 101” book. It is her account of growing into her womanhood, and a powerful testimony on the intersections of race, class, and gender. It is also interspersed with frank lessons on what it means to be transgender, and answers many questions readers may be afraid to ask (e.g. what does cis mean? What is bottom surgery?). While it is not a traditional medical humanities text, few in the medical profession can deny that they need a lesson in Trans 101, and for that reason it can be included as a valuable resource to learn from as a medical student. As well, it provides a compelling narrative on the role of physicians in a patient’s identity. Many pivotal moments in the book revolve around encounters with physicians, such as when she admitted to her doctor she had been taking her friend’s hormones, or when she arrived in Thailand for her gender-confirmation surgery and was greeted warmly by the team of nurses using her chosen name. Mock stated that she has felt “lucky” for the physicians she encountered because they were compassionate, considerate, and gave her the autonomy of choice despite her young age. Given the incredible adversity she faced growing up, it would be easy to think that her path may have been different if these physicians had been uncooperative. However, it is important not to overstate the role of the physicians in Mock’s journey. Throughout the book, Mock proved over and over that she is incredibly resilient, and to attribute any of her achievements to her healthcare professionals would be doing a disservice to Mock’s character. Redefining Realness is a firm reminder that stories belong to patients, despite the influence a physician may have on the outcomes.

rience; the objectification of her body as a young trans girl is a constant threat and consistent theme throughout the book. These details, however, are also the kind that medical professionals feel entitled to, and it would be naïve to assume this entitlement always comes from a place of medical necessity. Redefining Realness provides proof of the sheer volume of curious questions trans people field about their bodies, and urges medical professionals to be conscious, sensitive and respectful of this when discussing trans people’s health. It is an honour to be able to learn from our patients, but incredibly unfair if we expect them to use their experiences to educate us. This is why Redefining Realness is such a gift; through its open and honest narrative, it is able to teach us so many important lessons on the social contexts of health.

Mock has said in interviews that the chapter describing her surgery was the hardest for her to write, not because it was too personal, but because those details are the kind “cis people think they’re entitled to”. She speaks from a lifetime of expe-

Review by Maggie Hulbert, Meds ‘20