QMR - Volume 11, Issue 3 (2018)

QMR

QUEEN’S MEDICAL REVIEW

TRANSITIONS IN MEDICINE

Table of Contents ISSUE 11.3 TRANSITIONS IN MEDICINE Letter from the Editors

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Reviews & Reflections The Privileges and Burdens of Indecision Sachin Pasricha (Meds ‘20)

Essays & Creative Pieces

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Why Did We Want to be Doctors? On Medical School Admissions, the Curriculum, and Matching to Residency Bryan Franco (Meds ‘21)

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Changes and Growth During First Year Safia Ladha (Meds ‘20)

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Transitions in Care of HIV+ Patients Scott Wakeham (Meds ‘20)

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Global Advances in Medicine Avrilynn Ding (Meds ‘21)

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"How are You Doing?

Anonymous (Meds)

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The Journey Hissan Butt (Meds ‘20)

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Interview with Dr. Jacalyn Duffin Daniel Huang (Meds ‘21)

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History of Medicine Crossword (blank) Andrew Belyea (Meds ‘21)

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Transitions to QMed Palika Kohli & Sharon Yeung (Meds ‘21)

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The Patient Will Not See You Now June Duong (Meds ‘19)

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Interview with Andrew Thomas Ashna Asim (Meds ‘20)

History of Medicine Crossword (answers)

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Interviews

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

WRITERS & MANAGING EDITORS EDITORS Ashna Asim Andrew Belyea Avrilynn Ding June Duong Bryan Franco Daniel Huang Palika Kohli Safia Ladha Sachin Pasricha Scott Wakeham Sharon Yeung

Shannon Tang Ali Dergham

LAYOUT

Shakira Brathwaite Natasha Tang

ILLUSTRATION Hassan Hazari Martina Heinelt

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

Letter from the Editors Dear Readers, On behalf of the Queen’s Medical Review staff and contributors, we are delighted to share Issue 11.3: Transitions in Medicine. We are very proud of all the hard work and thoughtful effort that has gone into this issue. As a student-run publication, QMR always strives to serve as a platform for student voices, exploring a variety of perspectives and starting meaningful discussions. In this issue, we examine the many transitions we undergo in our careers in medicine from different outlooks, at different stages of training, and during different periods of time. Transitions are a huge part of medicine that greatly impact the care provided, and vastly shape the way we view and experience the field. The creative pieces, narratives, interviews, and articles included in this issue reflect on the different transitions we encounter, how we deal with them, and what we can learn from them. We hope you will join us on this journey of honesty, reflection, and self-realization.

The issue begins with an interview with the incredible Dr. Jaclyn Duffin conducted by Daniel Huang (2021), exploring transitions in the history of medicine as well as in her own career. Next, Sachin Pasricha (2020) explores The Privilege and Burden of Indecision. Following is an interview series conducted by Palika Kohli and Sharon Yeung (2021s) on the Transitions to QMed from the individual perspectives of first year QMed students Meg McPhie, Martina Heinelt, and Emily Wilkerson.

Bryan Franco’s (2021) article, Why Did We Want to Be Doctors, explores our draw to medicine and how that shapes the current conversation surrounding the residency matching process and is followed by Scott Wakeham’s (2020) article exploring Transitions in Care of HIV+ Patients. We then have Avrilynn Ding’s (2021) piece exploring the Medical Advances Around Our World. Following this we have two creative pieces, How Are You Doing? by Anonymous and The Journey by Hissan Butt (2020), that explore more personal aspects to the transition into medicine. An interview with Edward Thomas conducted by Ashna Asim (2020) explores The Legacy of the Black Alumni of QMed, expertly challenging and deconstructing almost a century of previously held notions. We then have a fun History of Medicine crossword created by Andrew Belyea (2021), followed by a personal piece by Safia Ladha (2020) exploring her experience of Changes and Growth During First Year. Finally, a powerful piece challenging our understanding of patient experience and diversity called The Patient Will Not See You Now by June Duong (2019) closes our last issue of the academic year.

As always, we would like to thank our extraordinary staff for their hard work and devotion. None of this would be possible without the contributions of our writers and editors, as well as managing editors Shannon Tang (2021) and Ali Dergham (2021) and layout designers Natasha Tang (2021) and Shakira Brathwaite (2021). Thanks as well to our amazing graphic designers Hassan Hazari (2020) and Martina Heinelt (2021) for all the artwork featured in this issue. Issue 11.3 is an informed examination of the changes we undergo and the experiences we gain which shape us as well as the medical field around us.

It is important to recognize the ways in which we come to understand ourselves and to critically examine the transitions we go through.

Thank you and we hope you enjoy exploring 11.3: Transitions in Medicine as much as we all enjoyed making it!

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

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INTERVIEW WITH DR JACLYN DUFFIN CAREER TRANSITIONS & TRANSITIONS IN THE HISTORY OF MEDICINE

Daniel Huang, Meds '21 perhaps more important to look at the errors—the things that got adopted that we now think are horrifying and we can’t understand why—because if you explore why something that seems so wrong now seemed right once upon a time you’re really asking questions about the prioritization of intellectual choices, and that’s exciting. So, that is a kind of method underlying the questions that I bring to specific things.

Dr. Duffin is a hematologist and historian who was the Hannah Chair of the History of Medicine at Queen’s University from 1988 to 2017. Her historical research has focused on disease, medical technology, religion, health policy, 17th century Latin author Paulo Zacchia, and most recently the 1964-65 Canadian Medical Expedition to Easter Island.

QMR: How do you choose your research interests?

JD: I’ve been very blessed in my life that nobody has told me what to do. Every single research project that I’ve done I’ve only ever pursued because it was a question that emerged, because someone asked me the question or because I had the question myself, and that just means my whole life has been a lot of fun. I was basically paid and rewarded to investigate the things I was curious about.

Some of my research is also social-conscience driven. I was very influenced in my life as a student by some philosophical works I read when I was in France about how it’s fun and exciting to study the great discoveries but it’s

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QMR: Has the field of medical history changed in your career?

JD: In history, there are philosophical trends. Everyone is fond of saying that in the past [it was] the great men biographical approach to history—very triumphalist accounts of the history of medicine. Then around the middle of the 20th century, people got tired and skeptical of that, and with an influence from France they became interested in longue durée as the French called it, where they were interested in the everyman and the average experience rather than the superlative experience. That really helped me get my first book published because it was on a complete nobody: country doctor north of Toronto who nobody had ever heard of, but he happened to have left all his records—40 years of records. So, that little project, my post-doc project, was timely because history in general, not just medical history, was interested in the average and the everyday.

At the same time, there was a big influence from feminism in women’s history.

Marxism was also a big influence when I began but then we experienced the fall of the [Berlin] Wall and then Marxism became problematic. We always say that

all history has to be rewritten in each generation because the past may remain the same, but history—what was written about the past and what we can read about the past—needs to be interpreted through our own questions and our own sensibilities. And so a women’s historian will go back and look at the same documents as a doctor from a hundred years ago and have a completely different analysis about what was going on.

"History - what was written about the past and what we can read about the past - needs to be interpreted through our own questions and our own sensibilities" QMR: How was the transition between your hematology residency and your history PhD? JD: Well, I wouldn’t have done history if I hadn’t reached a roadblock. My first husband was a doctor and he was killed in an accident, but I got the opportunity to marry again (to the man I’m still married to.) He was a diplomat and he was posted to Paris. I was not too long minted as a hematologist, so I moved

Interview

to Paris where they didn’t want me as a hematologist. So, I kicked around for a long time thinking about what I could do and kind of fell backwards into doing my PhD in history while I was in France.

QMR: How did you arrive at Queen’s?

JD: Eventually we came back to Canada and I got a post-doctoral fellow in history at the University of Ottawa while my husband was working in Foreign Affairs.

The whole time I was in Ottawa, those three years, I was trying to knock on the door of the hematologists because I didn’t want to be a historian. I didn’t plan to be a historian. I was only doing it to fill in the time. But, they didn’t want me because they were afraid of me, because I wasn’t that long in practice as a hematologist, because they didn’t really need a hematologist, and because I’d been doing history for three years. So, they thought I might kill somebody. I remember one hematologist told me, ‘Well, I need someone who does wet lab!’ and I’m going, ‘Well no, I’m sorry, I don’t do wet lab but I think I’m a safe clinician.’ And then a piece of good fortune happened and one of the hematologists got a sabbatical. She was francophone and none of the other hematologists could speak French, so finally, they wanted me. I became a fullfledged member of the team and they could see that I was safe even though I didn’t do ‘wet lab.’

Then, I had this shocking moment. I got offered the Hannah chair here at Queen’s the same day they offered me a job as a hematologist in Ottawa. I had to decide.

So, I went to the dean who had offered me the job in Ottawa and he said, ‘I offered

you the job because I’m happy to have you, but I’ll give you an old man’s advice about this: your research is in history and if you turn that wonderful job down in Kingston—these jobs are so rare, more rare than a hematology job—everyone will know, and then no one will think you’re serious.’ It was really interesting advice. It’s something I now tell other students. And, my husband ultimately made it possible. He took a leave of absence from Foreign Affairs and came to Kingston and hung out. He ended up doing a PhD while he was waiting for me, and now he works at Queen’s too.

So, a lot of it was luck.

other hematologists] treated me like a colleague and an equal. I had moments during the week—Thursday was my hematology day—where I’d get worried. I’d be afraid that I’d kill somebody, I wasn’t sure what was going to happen, and I’d walk down the street getting more and more apprehensive. Then I’d get to the clinic, walk in the door and it felt like home. Just the language, the lingo, the nurses, the requisitions for ordering things, walking into the room, and doing the thing that is so important in clinical skills—a line I love—‘putting the ill at ease.’ I was so grateful that nobody ever made me give it up.

"It is odd to go back and forth between medicine and history because when you're doing clinical medicine your default is optimism [...] when you're doing history, your default is skepticism"

But yes, it is odd to go back and forth between medicine and history because when you’re doing clinical medicine your default is optimism. You’re trying to help your patient get better, figure out what’s going on, and go forward. When you’re doing history, your default is skepticism.

I’m sure that the two identities have influenced each other in my personal delivery of history and my personal delivery of medicine. I feel that it’s almost like going through a mirror and becoming somebody slightly different each time because of the mix of the optimism of the clinical setting and of cheering for the patient, and then the historical skepticism about, ‘Were all these things fair? Were they accurate? Are they true?’

QMR: And what was it like to move between your job as a clinician and historian?

JD: So, every week I would go and help out in the hematology clinic and [the

Also, the historian has the luxury of taking time to figure out if something is true or not, but in the clinic we have to decide, and it’s an emergency if its leukemia or something like that. So, you go on the best evidence and you have to make the decision quickly and decide that you trust

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INTERVIEW WITH DR JACLYN DUFFIN CAREER TRANSITIONS & TRANSITIONS IN THE HISTORY OF MEDICINE

this, whereas in history you can lay it all out. They’re both evidence based disciplines; I love that parallel between them.

But, usually in doing a historical analysis you have several candidates for what the evidence might be. In medicine, we do too but we rely on p-values and that kind of thing to help us with our decisions.

QMR: How did you get medical history into the curriculum at Queen’s? That must have been a long transition.

JD: It was slow. But when I was interviewed for the job, I said that I wanted to do it. In my interview I had the idea that I didn’t want to give a course and I didn’t want it to be an elective. I said, ‘If I agree to give an elective, I’m agreeing that it’s not important. What I would like to do is infiltrate the whole curriculum.’

The committee—these were obviously doctors who like history—they liked that idea, and I didn’t do too badly on my job talk, and I got the offer!

But, when I arrived I had zero hours of lecture time. So, I got busy right away.

Beginning in the first month, in September 1988, I went around and made appointments to visit the head of every department—there were 25 departments.

And, I asked for an hour from every head. I only ended up with 3 out of the 25. Then, the school got accredited and there was patter in the school [about these classes] and each year I would get another two or three departments, and so, I’ve said previously in an article that the history of medicine classes became the intellectual equivalent of penis envy!

Every department that didn’t have one

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began to think it should.

QMR: It gave prestige.

JD: Yeah. So, it began slow but sure, and it was a transition. And the thing I insisted on for years was that I wasn’t going to teach any electives. If they wanted history, then core curriculum or not at all. And, I asked for one question on every exam.

I figured you wouldn’t fail if you got the history question wrong—you’d have to get a lot of other questions wrong to fail.

But you might pass if you got it right!

"I don't think we need to have the 'Lessons From the Past' approach to make it [history] worthy. It's just like how basic science is good in its own way" QMR: Looking back, how has being a historian influenced your clinical work?

JD: You have a long view in the back of your mind about things—[and are] aware the latest and greatest thing could turn out to be really bad. So, there’s a kind of caution about historians who go about practicing medicine, a kind of willingness

to worry holistically about their patients rather than about the scientific achievements.

QMR: And how has the clinic influence your historical research?

JD: I would say [research] questions grab me if I think they have an application to the present practice of medicine, and that’s where my being a clinician certainly influenced my choices as a historian. But, at the same time, I don’t think that’s the goal of history, I don’t think we need to have the ‘Lessons From The Past’ approach to make it worthy. It’s just like how basic science is good in its own way.

It doesn’t need to have an immediate knee-jerk application to the present. It’s exactly parallel.

MR: Looking ahead, how is the field of medical history changing?

JD: It is moving forward. And, [medicine] seems to be more sympathetic and more open-minded to history than it was. But, there’s another trend that’s happening and that is the health humanities movement. Now, I shouldn’t present them as an enemy, but health humanities is something that really caught on with medical educators, who are not humanities scholars. You could lump all that ‘soft stuff ’ off into one little thing, so you didn’t have to have an ethicist and an anthropologist and a historian and a literature person. Most medical schools want an ethicist because they want to prove they’re ethical: ‘Look, we have an ethicist so we don’t need to worry about it!’ So, on the one hand, all the medical

Interview

schools now feel like they should be able to demonstrate that they embrace humanities somehow, but because they have gone for this general word ‘humanities’, history has taken a hit.

QMR: What are some notable transitions in medicine itself that you’ve witnessed in your career?

JD: There are [new] diseases like AIDS, and Toxic Shock Syndrome, and SARS, infectious diseases that challenged our assumptions about what diseases are; AIDS in particular because it attacked the immune system. Zika, of course, is another. So there have been all kinds of diseases.

The advent of molecular medicine is hugely important. Hematology was fun to be in for that because we probably had the first [landmark] with the Philadelphia Chromosome. It was there when we were in medical school. So, it’s that old. It’s even older than me! But, because they

found that, it was a sign that you needed to look into genetics to understand diseases. And because we knew to look, we were able to make a molecular medicine, and the survival in that disease has radically been transformed. It was 3 years.

Now, it’s not. It’s longevity.

Added to that, I would say the next big paradigm is evidence-based medicine itself. Historians always laugh at that term because it implies there was no evidence in the past or it was only anecdote. It wasn’t only anecdote, and statistics have been used in medicine since the early 19th century. But, this idea of the randomized double-blind controlled trial as the gold standard of deciding when to change what you do—it owes a great deal to Canada, so it’s always important to mention. The guys at McMaster, Sackett and Guyat, they took what was already in the wind and gave it a term and they made people realize you can’t just take a trial, especially if it’s been funded by a drug company, and say, ‘So many people

got better and therefore [this drug] is better,’ you need to have robust controls, you need to have confidence, you need to understand the role of placebo etc. So it made statistics a workhorse for the field and it also holds a mirror up to how so many of our trials, even our good ones, are funded by drug companies.

QMR: Finally, do you have any advice for students on how to deal with the transitions we will encounter moving forward—in our education, and as medicine itself evolves?

JD: Transitions are numerous in medical education. It seems that the natural response might be nostalgia and gratitude for the past, coupled with curiosity, excitement, and trepidation about the future. But you cannot legislate emotion.

All you can do is try to enjoy the ride— always remembering it is an adventure and a privilege.

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Reflection

THE PRIVILEGES AND BURDENS OF INDECISION Sachin Pasricha, Meds ‘20 As medical students, we are constantly making decisions.

We must decide what type(s) of medicine we may want to pursue, what activities we want to invest our time in, and how to balance our lives. The importance of decisions is not new to our lives. Prior to medical school, we had to decide what profession to pursue, what schools to apply to, and for some, what school to attend. Beyond medical school, the decisions will continue and begin to affect more than just us, most notably our future patients. In fact, decisions are not unique to just medical students – they affect all humans.

At the risk of over-generalizing, what I notice is different with medical students is our attachment to certainty around these decisions. We are so attached to certainty, that at times, we fear the uncertainty that stems from indecision. A clear example is deciding what type of medicine to pursue. We actively seek out an answer to this through observerships from the start of medical school -- perhaps wrongly so.

Some of us get anxious when our classmates begin to determine their ideal career paths and we have not yet figured out our own. We get nervous that we have not yet decided. Even with the small things we become agitated by indecision. When a clinician tells us in a small-group learning session that

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more than one of the multiple-choice answers could be right, the complaints arise. Understandably, it is nice to know which is the “right” answer. However, medicine, and life, is not that simple. There is not always just one answer and sometimes there is beauty in appreciating the indecision.

Let us provide some examples. With the small group learning questions, having more than one right answer stimulates discussion. Moreover, it provides us with an opportunity to consider all possible treatments for our patient instead of being narrow-minded and having tunnel vision. Similarly, we can appreciate the state of indecision as it relates to choosing a type of medicine. If you were to have a pre-decided specialty of choice, you would view all the patients and diseases we learn about with that lens. If you knew you wanted to do emergency medicine and only emergency medicine, you would view all the aspects of stroke that we learn about from the perspective of an emergency medicine physician. While this is important and useful, you are at risk of missing the opportunity to consider how neurologists, neurosurgeons, interventional radiologists, physical medicine and rehabilitation specialists, internists, and family physicians interact with stroke patients.

All of this is to say that we as medical students appear to be drawn to certainty when faced with decision. And while indecision can be a burden, it can also be a privilege that we ought to acknowledge and appreciate. After all, medicine is ever-changing and by accepting indecision, we allow ourselves to become part of the progress of medicine.

Interview

TRANSITIONS TO QMED Palika Kohli & Sharon Yeung, Meds'21 For this issue, we spoke to some of our peers who transitioned from a different career path into medicine. We spoke with Meg, Martina and Emily about their lives, their interests and how they’re now finding medicine.

MEG MCPHIE

Meg trained in child clinical psychology.

She obtained her Bachelor’s degree in psychology at Queen’s University, and then went on to complete her Master’s and PhD in clinical psychology at York University.

Her research is focused in physical activity and mental health during adolescence. She just finished her internship at the Holland Bloorview Kids Rehabilitation Hospital, before starting medicine at Queen’s.

QMR: What is your story?

I initially chose to study psychology because my parents encouraged me in high school to pick a subject I wanted to study in university. I thought it was interesting to study why people behave the way they do. I declared my major in psychology and was on a pretty straight path from then on. I realized, near graduation, that it is tricky to get a job after doing your un-

dergrad in psych — most people have the intention to go on to grad school, which is typically either research or clinically focused. My degree was a Bachelor of Arts and wasn’t really science heavy; I only took biology in first year, and after that I focused on a broad range of psychology courses, such as social psychology and developmental psychology.

I graduated in from Queen’s in 2009, then took a year off, and spent it working in research. I applied to clinical psychology Master’s programs and ended up going to York University for their Clinical-Developmental Psychology program - that is, child clinical psychology. I spent two years completing my Master’s degree and the next five years doing my PhD. The program is a mix of research, clinical work, course work, and teaching. The final year was like our version of residency, where I did my clinical internship at Holland Bloorview Kids Rehabilitation Hospital in Toronto, which is a hospital devoted to children with disabilities.

Most of my clinical training was in psychological assessment, in comparison to psychotherapy. Assessment involves conducting standardized psychological testing to determine a child’s strengths and areas of need in terms of their thinking, learning and behaviour and generating recommendations Currently, I’m not registered as a child clinical psychologist — I would need to write my licensing exams. Naturally, everyone always asks me if I’m interested in psychiatry! But I am really not sure at this stage of my medical train-

ing. Psychiatrists and psychologists are quite different — in terms of treatment, typically psychologists tend to offer psychotherapy and other behavioural interventions, while psychiatrists have more varied treatment modalities available to them, including medication. The other issue is that psychologists can be really expensive, and therefore inaccessible to many in need, as they are not typically covered under OHIP. The suggested hourly rate is around $220, and most insurance plans only provide coverage in the range of $300-$1000 total. But for physicians, the bulk of what you do is covered by OHIP. In psychology, I found there were differences in the types of clients you would see, depending if you were working in the hospital setting, where services are covered, versus in private practice where families have to pay out of pocket. I found that families going the private route were more aware that a concern existed and were more motivated to get help, while this is not always the case in the public sector. Due to the high cost associated with private services, you tend to work with families who are of higher SES in private practice.

QMR: What are some similarities between what you were doing before and medicine?

MM: I think, unsurprisingly, that they are not too different in several regards. I think the major similarity is that they are both personal helping professions that involve front line patient care. Both of the training programs are fairly flexible in terms of how you spend your time —

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TRANSITIONS TO QMED — though this will change during clerkship and beyond. I also have a good understanding of interprofessional healthcare teams through my training in psychology — I’ve worked with OTs, PTs, social workers, dietitians, nurses, child life specialists, and physicians in the past.

M A R T I N A H E I N E LT

QMR: What are some of your interests outside of medicine?

MM: I really enjoy keeping active and going to the gym. I try to spend as much time as I can outdoors, which is also a must with my high energy dog. I also cook a lot, and love trying new foods and going to new restaurants. I’m also a fan of fine art. My parents fostered my love for art from an early age, enrolling me in pottery and arts & craft classes. After I finished high school, I took part in an art program abroad in Florence, Italy, where I studied photography. I love Cezanne, and I have been fortunate enough to spend some time in Europe - in Rome, Paris, Amsterdam and Bruges, during my research activities on the most part, where I could visit some of the famous galleries in my free time.

QMR: What inspires you? What are some things you hope to accomplish?

MM: I hope to use some of my knowledge and skills in clinical psychology to better myself as well as my work as a physician. I really want to use my prior training, in some capacity, to be a part of my practice. I do not want to end up losing those skills. I want to improve the care I deliver and use it in the ways which I interact with my future patients. I think generally, it is important to understand the impact of mental health on a person’s functional well-being, and I hope to help increase awareness of existing services available, while also encouraging increased access to mental health services across all disciplines.

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Martina is an engineer who trained at the University of Toronto. She studied engineering science, specializing in biomedical engineering. Throughout her undergraduate, she conducted research in physics, paramedicine, stem cell engineering, release kinetics and polymer research. Her research was done in a variety of places, including Singapore, Boston and Toronto.

QMR: What is your story? Why did you choose medicine?

MH: I didn’t know if medicine was what I wanted after I finished high school. My mom is an internist and toxicologist, and I wasn’t convinced that this is what I wanted to do with my life. I enjoyed math and science, as well as the arts, though I had been given the message that things like writing were for hobbies, not careers. I ended up choosing engineering and studied biomedicine after attending a talk given by Dr. Ginsberg at St. Michael’s Hospital in Toronto. He developed medical devices and is an engineer, surgeon, inventor and entrepreneur. He inspired me to choose biomedical sciences, and once I was there, I knew I wanted to go into medicine. I learned, especially during my research in creating medical devices in Boston, that it’s way better do this with an MD, because you have both sides and experiences informing your work.

Interview

QMR: Do you think you would have been happy if you had decided to stay in engineering?

MH: I think I would’ve ended up happy. I believe it’s possible to find happiness in whatever you’re doing, as long as it’s something that challenges and engages you. I never disliked engineering - in fact, I liked it! I knew that I wanted to implement it later on in my life. While I was studying it, I wanted to combine it with medicine, or medical research. I think choosing engineering would mean that though I would have taken a different path, I would have come to potentially the same conclusion.

QMR: What area of medicine are you interested in?

I know that I’m interested in surgery, but I don’t know much more than this! I know that I need to do things with my hands.

I hate being behind a computer all day, which is what a lot of physicians and specialists do, so I know I don’t want that.

QMR: What outside of medicine are you interested in?

I powerlift. The class of powerlifting I’m involved in is more regulated and is focussed on depth and form. I’ve been powerlifting for three years. Before that I played tennis competitively, though I stopped after I hurt my back pretty badly. One of the reasons why I like powerlifting is that you can do it for your whole life, because the masters goes on. There are 75 year olds, and even 95 year olds who powerlift competitively.

You don’t peak! I also enjoy horseback riding, though I can’t do it that often because it’s quite expensive, inaccessible and time-consuming. I’ve been riding since I was 7 years old.

I’d chosen to do my masters or PhD. I miss feeling younger, because often I feel as though I’m running out of time to do the things I want to do. But I know this isn’t right, and I try to fight against this notion. I’ve heard so many people say, oh you know, this is our last summer, so we’ve really got to enjoy ourselves! But we don’t have one last summer. We don’t have one determined path. I want to work to not give into the pressure to do “the things that we’re meant to do”, to follow these prescribed paths. I want to fight this culture in medicine, this idea that we can’t take breaks.

QMR: What inspires you?

Creating things, doing things that are new. So many people do things because that’s what other people have done. Most people go to school, save money, retire. They do this because it’s what everyone else does. I want to invent a medical device, to create something that hasn’t been made before! Like Dr. Ginsberg - he created something out of nothing. I don’t just want to work at a company or a hospital and just get a job with them and work there. I know that it’s easier to do this, but I think that there’s limited value added with that kind of a system. Even the most brilliant surgeons have lineups of people behind them waiting to replace them. I think that it’s not good to be too comfortable or too uncomfortable - in both cases you end up unproductive. I want to start my own clinic. I want to move forward, to do something different - to think differently, to create something. The question I always ask myself is how can I do things differently to add value in a way that can’t be, or hasn’t been, added elsewhere.

QMR: What do you miss most about your life before medicine?

I feel older now, like I’ve been through a big transition in my life. I’m not sure if I’d feel this way in another path, like if

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TRANSITIONS TO QMED E M I LY W I L K E R S O N Emily is a classically trained singer who studied Opera at the University of British Columbia. After obtaining her bachelor’s degree in Opera, Emily volunteered teaching music in Belize, started a second degree in Health Science and worked at a pain clinic.

QMR: What is your story? What led to your choosing medicine?

EW: I have had a love of singing since I was in elementary school. Music has always been important in my family - my mom’s three brothers all did their degrees in piano, and my mom was an elementary school music teacher. My dad also loves 70s music - some of my favourite memories are of us going on road trips through Okanagan and singing along to the songs from the musical, Joseph and the Amazing Technicoloured Dreamcoat. When I was in Grade 7, my school put this show on and I was the narrator. I sang the whole thing from start to finish, and I still remember people saying that it was the best show the school had ever seen.

I also loved science a lot - I was ahead of my classmates in these subjects and didn’t have a lot of friends growing up who were interested in the same things as me. Later on, in high school, I had to make the choice between science and singing, because even though I loved music, I also had this dream of going to medical school. I ended up choosing singing. In grade 11, I went on this missions trip to Peru, where I helped build houses. I remember thinking to myself, what the hell am I doing singing? I’m not going to help anyone singing. But my friend, who was on the trip with me, said to me how my voice touches people, that my singing is so meaningful. This meant so much to me, and made me decide that I was going to do it.

I auditioned at UBC and got in. I studied opera. It was really intense, and at times stressful, but I loved singing so much I got through it. In my third year, I got really sick. I developed acid reflux and was really stressed out. I would sing for ten

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minutes and then start coughing. At that point, it was like not having enough money for rent! My voice is my instrument, it’s not like I can fix my piano and return to practicing. And I realized then that my voice is also my livelihood - if it breaks down, I have nothing, and then where would I be? So much depended on if my voice worked or not. I found this super stressful, and it made me realize that I wanted something different for a career. I decided to do something else. I took a bunch of prerequisite science courses, which I found very difficult. I had to relearn how to study - those couple of years were just awful. But I was really determined - and then I found out I got into medicine.

QMR: What are some surprising similarities between what you were doing before and medicine?

EW: Singing taught me a lot about how to work with people - a “transferable skill,” as they’re calling them these days. I learned at UBC that people aren’t always nice or always looking out for you, and that there is a lot of competition out there. If you can

Interview

learn how to tune that out, you become so much better - both for yourself and at what you do. I learned that lesson the hard way in opera, but I think it was a completely valuable lesson to learn. It also taught me so much about self-awareness and emotion, how to work through feelings, how to turn them on and off. I believe that having emotional intelligence is really valuable. When you know your own emotions, you learn to read other people’s emotions. And really, music is about learning to communicate emotions. That’s really all what art is - learning how to communicate emotion.

In medicine, I’m learning a different form of communication now, like using x-rays and things like that. And really, learning to read people, giving them the time to speak with you - that’s how you’re going to learn to communicate with your patient.

We’re also going to need to learn to communicate with nonverbal patients - and art is how you might do that.

QMR: You’ve talked about experiencing your emotions in a physical manner quite a bit. You’ve also alluded to the fact that the way you think is deeply influenced by the arts.

Could you speak to how that impacts you?

EW: Your question reminds me of my uncle, who did his piano degree at McGill. He was an incredible blues musician. We have a beautiful photo of him playing the piano at my grandma’s house. One day we were talking about it, and my mom told me that he said, “even though I feel so much sadness, I wouldn’t trade that for the joy I get to feel in those moments”.

He was very emotional, and he would feel great highs, but also the deepest lows. Sometimes this isn’t the easiest way - I mean, instead you can flatline, and I’ve been there - you can turn your emotions off. It’s a steadier state, but you also don’t experience joy as meaningfully. One doesn’t come without the other. Have you ever felt so happy, that nothing could touch you, that you’re sparkling with happiness? I have. And even having felt that shittiness, the lowest lows, I still wouldn’t trade that with anyone who can’t feel the joy I’ve felt. It’s what I feel when I’m singing, where I’m basically saying, “here I

am - take me as I am”. Singing is about opening yourself up and feeling vulnerable, and the energy you receive in return is just incredible. This past year I’ve been singing more than I have in the last three years. I cry even if I’m just singing in the shower or driving - it’s such an intensely physical response. It’s better than working out - I feel so hungry after!

Sometimes I have to dial this down and try to take things more logically. I look at a patient and hear their story, and I feel that emotion. It’s easy for me to get it - it’s what I’m attuned to.

Sometimes when I watch others interact with patients who are less attuned, I get nervous. Like, if people are talking to patients and are just saying a bunch of orders, I want to be like - hold the phone! The patient is overwhelmed! Sometimes I feel that people just don’t realize how important each and every person’s experience is.

QMR: What inspires you?

EW: The way I used to think about inspiration was in terms of grand gestures of passion and determination and strength.

Now I see it as these little light bulb moments. I see something and think, that would be something I’d be willing to invest my time in. Or with people - if you look at someone and see what they do as worthwhile, or if they give strength to you.

My mom inspires me! She answers all of my phone calls and listens to me as I scream and cry and yell and swear and she takes all of that. I want to be like that and have the strength and courage and resilience to live everyday life. Because every day is really hard.

In medicine, I’m inspired by babies, and giving birth. How a body can produce another human is beyond me. And I’m not just talking about the physicality of it — I’m talking about life and the idea of birth, existentially. Obstetrics and gynaecology — that is cool. I did a labour and delivery observership, and watching a mom push out a baby — that was inspiring to me!

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WHY DID WE WANT TO ON MEDICAL SCHOOL ADMISSIONS, THE HIDDEN Bryan Franco, Meds'21 “Why do you want to be a doctor?” is the question I, like most aspiring physicians, asked myself before medical school. It forced me to better understand my goals and passions. As a result, I was able to claim with confidence that I wanted to make a difference by practicing medicine during my medical school admissions interview.

As I approach the end of first year of medical school, I asked myself the same question. Why do you want to be a doctor? My answer surprised me. My passion for medicine has strengthened as I learned about the profession, but I had unknowingly added conditions to my goal of “making a difference.” I realized that I still desire to help people, however, I was drawn towards certain conditions and patients.

Some would argue that this is simply a medical student determining which specialty to pursue. However, with an unprecedented number of unmatched Canadian medical graduates and large number of unfilled family medicine residency spots [1], I speculate on my future self ’s answer to “why do you want to be a doctor?”

Medical students are selected for their ability to identify and reach a goal – in fact, most can tune into what is expected of them and highlight desirable qualities [2]. Thus, admission committees and policies heavily influence an aspiring physician’s answer to “why do you want to be a doctor?”. In other words, the “hidden curriculum” is present even before any medical education begins [2]. Medical students, by virtue of the admissions process, are competitive and have been generally successful in achieving their goals. We, for better or for worse, know how to play the game.

The pervasive hidden curriculum continues to influence medical students throughout their training [3] and consequently shapes the future physician workforce in Canada. It perpetuates the culture of medicine, imparting beliefs that value competition over cooperation [3] and specialist care over generalist care [4]. Future physicians’ negative attitudes towards family medicine is perhaps the most obvious and detrimental result of the hidden curriculum [5].

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What do school medical school admissions, the hidden curriculum, and matching to residency have in common? They all heavily influence medical students’ answers to “why do you want to be a doctor?” Medical school admissions select for competitive individuals who have been successful for their entire lives. Afterwards, the hidden curriculum nudges students towards specialization. While not true for everyone, it is reasonable to expect that this drives medical students, who are accustomed to excelling in their endeavours, toward competitive specialties and residency programs. After all, we were lucky enough to beat the odds when applying to medical school and past experiences taught us that we can overcome any challenge – why would we refuse another one?

"Medical school admissions select for competitive individuals who have been successful for their entire lives... it is reasonable to expect that this drives medical students toward competitive specialties The problem of the growing number of unmatched medical graduates is complex. Fortunately, an array of stakeholders, from program directors to government representatives, have been engaged to solve this problem. Ultimately, everyone involved wants to fix the apparent disconnect between the health care system needs and physician training.

I argue that to effectively tackle this problem, there is another important stakeholder that must be considered: medical students before they became medical students. “Why did we want to become doctors?” becomes an increasingly important question. Do we want to make a difference in people’s lives

Reflection

O BECOME DOCTORS?

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C U R R I C U LU M & R E S I D E N C Y M AT C H I N G

through medicine regardless of specialty? Are we willing to fill gaps in the health care system wherever required? Are we willing to sacrifice “prestige” or what is “medically interesting” for us to meet the needs of Canadians?

Answering these questions are difficult and only becomes harder the longer students are immersed in the culture of medicine. However, honest answers are essential to guide any reforms to the residency matching process. Failure to consider this perspective will leave us with a matching process that not only exacerbates the number of unmatched medical graduates, but also increases the mismatch between health care needs and the physician workforce.

References 1. The Association of Faculties of Medicine of Canada, Reducing the number of unmatched Canadian medical graduates.

2018, The Association of Faculties of Medicine of Canada: Ottawa, ON. 2. White, J., et al., "What Do They Want Me To Say?" The hidden curriculum at work in the medical school selection process: a qualitative study. BMC Medical Education, 2012.

12(1): p. 17.

3. Lempp, H. and C. Seale, The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ, 2004. 329(7469): p.

770-3.

4. Haidet, P. and H.F. Stein, The role of the student-teacher relationship in the formation of physicians. The hidden curriculum as process. J Gen Intern Med, 2006. 21 Suppl 1: p. S16-20.

5. Collier, R., Disrespect within medicine for family doctors affects medical students and patients. Canadian Medical Association Journal, 2018. 190(4): p. E121-E122.

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TRANSITIONS IN CARE OF HIV+ PATIENTS Scott Wakeham, Meds'20 The history of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) around the world is filled with controversy, prejudice, social activism, and highlighted inequities. While HIV/AIDS still kills an estimated one million people per year globally, treatment has been revolutionized from a terminal diagnosis to that of a chronic disease. In Canada specifically, an estimated 75,500 Canadians were living with HIV at the end of 2014. In the developed world, HIV is most common in gay men and other men who have sex with men (MSM). Heterosexual sex comprises approximately 30% of transmissions, and intravenous drug use another 20%. Likely due to stigma, lack of access to resources, or lack of awareness of risk, 1 in 5 Canadians living with HIV are unaware that they have HIV. The greatest proportion of these unaware individuals had transmission via heterosexual sex.

When HIV first came to the scene in the 1980s, it was not treated as the epidemic that it truly was. Faith organizations called patients with HIV an abomination, and an article was published discussing the ability of physicians to refuse to treat a patient who is HIV+. Gay men faced an epidemic of hate and insensitivity, while their friends died around them from an unknown and underexplored cause. Globally,governments and scientific institutions turned a blind eye to the disease that was claiming hundreds of lives, with the Reagan administration refusing to even mention the word ‘AIDS’. The social activism group Gay Men’s Health Crisis was formed in response to hospitals refusing to treat patients with AIDS. When it was discovered that HIV was a virus and needed therapy, groups such as the AIDS Coalition to Unleash Power (ACT UP) began to form internationally to lobby for research and government action for this marginalized group. When AZT (zidovudine) was developed as the first drug to treat HIV/AIDS, regulatory bodies in the US failed to expedite drug approval, leading to fomation of an underground market of ‘Buyer’s Clubs’ that effectively ran the first US clinical trials of these medications.

Unfortunately, this treatment, along with other newly developed treatments, failed to provide a cure, and many did not

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significantly slow progression of the disease.

Poor prognosis and care of HIV patients continued for over a decade, until the International AIDS Conference in Vancouver 1996. Protease Inhibitors, a drug class for HIV treatment, were announced. Within a week of the conference, nearly 75000 patients with AIDS in developed countries started these medications. Along with other classes of medication, these agents formed highly active antiretroviral therapy (HAART), used to decrease a patient’s viral load and improve their CD4+ T cell count. These agents revolutionized care for patients with HIV and allowed people to live longer and live with fewer opportunistic infections and malignancies. This treatment allows patients to have a near-normal life expectancy. Additionally, when taken as prescribed, HAART can reduce circulating HIV virus (aka viral load) and reduce the risk of transmission. It has been studied that a person with an undetectable viral load carries approximately the same risk of HIV transmission as someone without HIV. To date, there has not been a single case of sexual transmission from an HIV+ partner who is regularly involved in HIV care, is compliant to their HAART, and has an undetectable viral load.

Another advent in the care of HIV/AIDS care is the development and use of pre-exposure prophylaxis (PrEP). This is a once daily combination medication of emtricitabine/tenofovir (Truvada) that allows individuals at risk of HIV infection to reduce risk of sexual transmission by >90% and of injection drug transmission by >70%. Without drug insurance, this medication can be hundreds of dollars per month. Thankfully, many private and public insurers, including OHIP+, cover the cost of PrEP. Although covered, people at risk currently experience difficulty in access to PrEP due to lack of physician awareness and comfortability with prescribing.

Although many advances have been made in the care of patients with HIV, there are still opportunities to improve care. Many trials for an effective HIV vaccine have failed, but development still continues. Ingenuity and further drug development is also

Essay

required for drug resistant strains of HIV that are appearing more frequently. Unfortunately, HIV/AIDS continues to be a devastating disease in the developing world and for those without access to care. In the developed world, social and political stigma still exists against people with HIV, though to a much lower degree than 30 years ago. From an epidemic

that claimed the lives of many, to a medical condition that can be treated much like a chronic disease, HIV/AIDS is a disease that has been conceptualized and revolutionized within our lifetime.

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GLOBAL ADVANCES IN Avrilynn Ding, Meds'21

1.

Canada, March 2018. Air Pollution & Gene Expression It is well known that the environment impacts human health.

However, a team of researchers have concluded that environmental factors can have a stronger influence on gene expression than genetic ancestry. Analysis of 1007 French-Canadian Quebec residents and their peripheral blood gene expression found that regional environment exposures, particularly air pollution, accounts for the expression differences of a greater number of genes than regional ancestry. A majority of the differentially expressed genes are associated with disease traits or inflammation. Therefore, strategies that use genetic sequencing to predict an individual’s predisposition to medical conditions are likely only capturing one part of the story.

Favé M-J, Lamaze FC, Soave D, Hodgkinson A, Gauvin H, Bruat V, et al. Gene-by-environment interactions in urban populations modulate risk phenotypes. Nat Commun. 2018 Mar 6;9(1):827.

4.

Costa Rica, March 2017. Zika Vaccine The phase 2/2b clinical trial of the Zika vaccine is now underway in Costa Rica, as one of the areas where there is confirmed or potential active mosquito-transmitted Zika infections. Other countries included in the trial include the United States, Puerto Rico, Brazil, Peru, Panama, and Mexico.

The Costa Rican Centre of Medical Investigation (CCIM) is in charge of carrying out the study. Healthy adult volunteers, aged 18 to 35, from metropolitan areas who have not been infected by the virus and are willing to participate for a 2-year period will be recruited. The DNA vaccine was developed by the National Institute of Allergy and Infectious Diseases.

A phase 1 trial in 2016 showed that the vaccine was safe and induced a neutralizing antibody response against the Zika virus. The phase 2/2b trial will evaluate the vaccine’s safety and ability to stimulate immune response, as well as determine an optimal administration dose.

Phase 2 Zika vaccine trial begins in U.S., Central and South America [Internet]. National Institutes of Health (NIH). 2017 [cited 2018 Apr 1]. Available from: https://www.nih.gov/news-events/news-releases/phase-2-zika-vaccine-trial-begins-us-centralsouth-america

5.

Uganda, February 2018. Blood-free Malaria Test Engineers in Uganda won an award for their malaria diagnostic test that does not require a blood sample. The low-cost reusable device clips onto a patient’s finger and shines polarized red light to detect changes in the shape, colour, and concentration of red blood cells caused by malaria. A magnet in the device also detects hemozoin crystal, a byproduct of the malaria parasite that is magnetic. Results are displayed on the Smartphone linked via an app. The test takes less than 2 minutes to return a result. However, its major advantage is that patients can conveniently test for the disease in their own home instead of having to be in clinic. The current specificity of the test is 80%, so priority is to continue refinement and vigorously evaluate its specificity and sensitivity.

Hodal K. The magnets and light beams that signal an end to blood tests for malaria [Internet]. the Guardian. 2017 [cited 2018 Apr 7]. Available from: http://www.theguardian.com/global-development/2017/dec/27/magnets-lightbeams-end-blood-tests-malaria-uganda-sub-saharan-africa

S IN MEDICINE

8.

China, March 2018. Gut Microbiome and Diabetes Many clinical trials have suggested that a high-fibre diet improves outcomes for type 2 diabetes mellitus (T2DM), but patient responses are variable. A recent study identified a specific group of gut microbiota that are responsible for the benefits of a high-fibre diet. The diet promotes the growth of short-chain fatty acid (SCFA)-producing gut bacteria, which produce SCFAs that serve as an energy source to colon epithelial cells, regulate appetite, and decrease inflammation. The diversity and abundance of 15 SCFA-producing bacteria strains correlated with greater improvements in glycemic control, blood glucose level lowering, and body weight reduction. Growth of SCFA-producers also reduced microbes that produce metabolically detrimental compounds. This understanding of how gut microbiota responds to dietary changes indicate the targeted restoration of SCFA-producers may improve the efficacy of dietary interventions for T2DM patients.

Zhao L, Zhang F, Ding X, Wu G, Lam YY, Wang X, et al. Gut bacteria selectively promoted by dietary fibers alleviate type 2 diabetes. Science. 2018 09;359(6380):1151–6.

10.

Sweden, March 2018. Coding Data from Neurons Advances in brain research place increased demands on databases and data processing software. Major challenges include the volume of information involved when analyzing and sending signals, and the fast data interpretation required to facilitate meaningful communication. Researchers from Lund University in Sweden developed a method to store and manage data from neurons so that it communicates back in 25 milliseconds. Neural signals are recoded into bit-code, a format that greatly increases storage capacity and allows computer processes to immediately access it. The software can simultaneously collect data from over 1 million neurons, analyse the data, and send feedback within milliseconds. It can also operate through long periods of recording time and allow two-way communication between neurons. Future work will be to scale up the software architecture to support a brain-machine interface.

Ljungquist B, Petersson P, Johansson AJ, Schouenborg J, Garwicz M. A bit-encoding based new data structure for time and memory efficient

7.

Singapore, December 2017. Artificial Intelligence Diabetic retinopathy is currently diagnosed using manual assessments of retinal photographs. Researchers in Singapore developed and trained a deep learning system to classify retinal images into those with or without diabetic retinopathy, glaucoma, and age-related macular degeneration. The Artificial Intelligence (AI) was trained and evaluated using 494,661 retinal images from people of different ethnicities from the US, Australia, China, Hong Kong, Mexico, and Singapore.

For detecting vision-threatening diabetic retinopathy, the AI’s sensitivity is 100% (94.1-100) and specificity is 91.1% (90.7-91.4). For less severe diabetic retinopathy, possible glaucoma, and age-related macular degeneration, its sensitivity is greater than 90% and specificity is greater than 85%. The AI system is currently in beta testing phase and used alongside human graders.

Ting DSW, Cheung CY-L, Lim G, Tan GSW, Quang ND, Gan A, et al. Development and validation of a deep learning system for diabetic retinopathy and related eye diseases using retinal images from multiethnic populations with diabetes. JAMA. 2017 12;318(22):2211–23.

handling of spike times in an electrophysiological setup. Neuroinformatics. 2018 Mar 5;

Turn the page for more insights!

GLOBAL ADVANCES IN MEDICINE 2.

United States, March 2018. Male Birth Control Pill A male birth control pill that is safe, effective, and does not harm sex drive may have finally been found. Like the oral contraceptive for women, dimethandrolone undecanoate (DMAU) combines the activity of androgen and progestin. A double-blind clinical trial with 83 men monitored for 28 days showed that DMAU significantly decreases testosterone, luteinizing hormone, and follicle-stimulating hormone levels. The few subjects who reported testosterone deficiency symptoms, such as lower libido, had their symptoms resolved by the study’s end. DMAU also showed no liver toxicity and contains a long-chain fatty acid that slows its clearance, allowing it to be taken once daily. Future studies to measure sperm count, and with a larger sample size and longer monitoring period are required.

Thirumalai A, Ceponis J, Amory JK, Swerdloff RS, Surampudi V, Liu PY, et al. Pharmacokinetic and pharmacodynamic effects of 28 days of oral dimethandrolone undecanoate in healthy men: A prototype male pill. Oral session presented at: ENDO 2018, Annual Conference of the Endocrine Society; 2018 Mar 17-20; Chicago, IL.

3.

United States, March 2018. Pan-Cancer Treatment Larotrectinib is the first cancer drug to have received approval as a FDA breakthrough therapy for patients positive for a fusion gene, regardless of cancer type. Larotrectinib is an oral kinase inhibitor that targets tropomyosin receptor kinase (TRK). TRK fusions occur in many cancers, particularly rare pediatric cancers. A phase 1-2 clinical trial showed Larotrectinib achieved a 93% objective response in TRK-positive pediatric patients. The previous month, published results from trials involving 55 cancer patients with 17 unique TRK fusions, ranging from the age of 4 months to 76 years, also showed a 75% (61-85 %) overall response rate. Larotrectinib may become the first cancer therapy to be effective on its target across all cancer types.

Laetsch TW, DuBois SG, Mascarenhas L, Turpin B, Federman N, Albert CM, et al.

Larotrectinib for paediatric solid tumours harbouring NTRK gene fusions: phase 1

results from a multicentre, open-label, phase 1/2 study. Lancet Oncol. 2018 Mar 29; Drilon A, Laetsch TW, Kummar S, DuBois SG, Lassen UN, Demetri GD, et al. Efficacy of Larotrectinib in TRK fusion-positive cancers in adults and children. N Engl J Med.

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2018 22;378(8):731–9.

6.

Australia, March 2018. Superbug Immune Evasion Gonorrhoea, a disease that affects over 100 million people worldwide each year, is caused by the bacteria Neisseria gonorrhoeae (N. gonorrhoaea). N. gonorrhoaea has no effective vaccines and is rapidly developing resistance to all known antibiotics. It establishes infection by escaping the innate immunity. Recently, researchers discovered the mechanisms through which it accomplishes this. Using new super-resolution microscopy, they observed that the small bacteria creates even smaller packages of membrane called vesicles. The vesicles are taken up by macrophages, and trigger macrophage apoptosis via activation of caspase-3.

The discovery of this mechanism provides a target for new antibiotics. Strategies preventing this process can block immune evasion and allow the body’s immune system to kill the bacteria.

Deo P, Chow SH, Hay ID, Kleifeld O, Costin A, Elgass KD, et al. Outer membrane vesicles from Neisseria gonorrhoeae target PorB to mitochondria and induce apoptosis. PLoS Pathog. 2018 Mar;14(3):e1006945.

9.

United Kingdon, March 2018. First Oral Vaccine Researchers created the world’s first synthetic, non-biologic oral vaccine. The new influenza-A vaccine, in the form of a pill, is made from synthetic peptides that mimic those in the real virus. Standard vaccines are administrated via injection because the antigens are susceptible to digestion if eaten. The majority of natural proteins are constructed from L-amino acids, which are highly susceptible to protease degradation. The synthetic vaccine is created from D-amino acids, an enantiomer of the influenza A antigen. D-amino acids have identical chemical and physical properties to L-amino acids, but are resistant to protease-mediated hydrolysis. The study showed that in vitro, the synthetic peptide triggers a strong immune response in human influenza virus-specific CD8+ T cells. In mice, following oral administration, the vaccine generated cells that killed the influenza virus. It will take several years before the vaccine can be ready for human clinical trials. Since oral vaccines are much easier to store, transport, and use, its successful development will have particularly positive implications for developing countries.

Miles JJ, Tan MP, Dolton G, Edwards ES, Galloway SA, Laugel B, et al. Peptide mimic for influenza vaccination using nonnatural combinatorial chemistry. J Clin Invest. 2018 Apr 2;128(4):1569–80.

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"HOW ARE YOU DOING?" I’m great! …

I’m good! …

I’m fine! …

It’s okay. …

I’m a little stressed.

There’s so much going on.

I feel tired a lot.

I just couldn’t bring myself to study that hard for this one, but I’ll work harder on the next one. …

It’s just a RAT. It’s just a test.

It’s just a midterm.

You can fail one final they won't kick you out.

I’m gonna be around this summer anyways. …

I’m doing so much better now.

I’ve got this. …

Sometimes I find it hard to wake up in the morning.

Sometimes it’s hard to sleep at night.

I can’t stand to be around anyone.

I just need to be around some people today.

I’m so alone.

There’s so much to do.

I can’t keep up with everyone I want to see. …

I need to go out more.

I need to go out less.

Do I even like going out? …

I don’t think I’m ready for the real world. …

I need to get out of the classroom.

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Creative

…

Does anyone else feel like this?

Everyone feels like this.

No one feels like this.

I’m alone.

I’m surrounded. …

I’m burnt out.

I’m euphoric.

I love what I’m learning.

I wish we didn’t have to learn today.

Can I learn this later?

Will I learn this later? …

I honestly don’t know “I’m great!”

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THE JOURNEY Hissan Butt, Meds '20

The journey I conquered the journey before I begun. I dwelled there, had reached there, I had already begun. I think I may have walked there. I was there on the road walking, which was hard for sure, walking, walking. There must have been things on the way probably, I can’t say for sure. I reached there, later, some time later, or maybe it took a while. It must have otherwise I would have been there already. There, sitting there, not walking, sitting there, in an abode perhaps, my abode perhaps, some abode perhaps, a roof perhaps, to save me from my nakedness in which the stars found me, smiling at me, while the struggling veins of the murderous nights bursted with bloody darkness. The thought ran through me like water, flooded me as if it had stepped from there, secretly, silently, the way thoughts usually come, as an uninvited guest that stays and lingers on and we find solace in his company, find his company bearable until we think he is our very own and he walks away silently the very way he came in.

I stayed there. I think I did. The rest I can’t seem to remember.

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THE LEGACY OF BLACK ALUMNI OF QMED:

INTERVIEW WITH EDWARD THOMAS Ashna Asim, Meds'20

Queen’s and the worst thing. I decided I’d start by looking at the worst thing — the notorious expulsion of black medical students.

I started last February. By the end of two evenings’ effort in public electronic archives, I’d debunked key pieces of the official story. Not only that, I had found a much larger story: That Queen’s had been the leading Canadian center of Black professional education in Canada. That it destroyed this role by initiating its own anti-Black race policy. That Queen’s black medical alumni had gone on to change the world. And for at least 100 years, the university hadn’t cared to know this had been the case.

QMR: Could you please tell us a bit about yourself?

ET: I was a journalist who became an engineering researcher and later a research and innovation administrator at Queen’s.

I have been at Queen’s in one capacity or another since 2002.

Since 2008, I have helped hundreds of the university's internal and external partners acquire resources supporting basic and applied research, major networks, technology commercialization, entrepreneurship, training and regional development.

QMR: How did you get started on this research?

ET: In February 2017, I attended a PICRDI [Principal’s Implementation Committee on Racism, Diversity, and Inclusion] townhall for Queen’s staff, students and faculty to voice their concerns about racial inequality. The community's conversation on the subject seemed to be circular, fraught and fragmented.

It struck me that there was nothing like a coherent narrative of the university’s history of race.

I’m not a critical race theorist, or a sociologist. But I did think I could make a bit of narrative-building progress on race by trying to understand the best thing that ever happened to

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"Queen's had been the leading Canadian center of Black professional education in Canada... it destroyed this role by initiating its own anti-Black race" QMR: If you could re-write the Queen’s Encyclopedia entry on “Black students, expulsion from medical school” – what are some key points you would emphasize?

ET: The entry (as it stands in Spring 2018) will have to be completely rewritten, of course, as its assertions are almost entirely false.

The objective facts of this history between 1918 and 1964 will, in due course, need to be recorded faithfully in the encyclopedia.

The key subjective themes (in my mind) include: The university concocted a false narrative around this story and that narrative has lasted a full century. It may be our worst epistemological failure as well as our worst moral failure. The story was revisited by the Faculty’s own authorities in 1919, 1928, 1964, 1978, 1986, 1988 and 2007. There was a docu-

Interview

ment trail each step of the way. There was a counternarrative at each step of the way. And yet we somehow managed to delude ourselves that 1) we weren’t really responsible for our own race policy and 2) disadvantaging black students had no noteworthy consequences.

QMR: You have commented that Queen’s was on track to be a "critical node in the civil rights movement" and the postcolonial conversation. Could you please further expand on why and how Queen's was poised to be a critical node in the civil rights movement?

Medicine, and the university as a whole, estranged itself from the legacies of very important alumni. It is altogether incredible to imagine that Hugh G. H. Cummins, Simeon Hayes, Clement C. Ligoure, Ethelbert Lowe, or Frederick Holder would not merit so much as a single mention at Queen’s in 100 years.

Queen’s prejudice inflicted terrible damage on its mission and reputational growth. We trained a score of significant world-changers and were on a pace to train many more.

ET: The biographies of the 1900-1922 black alumni plainly show their historically important roles in 20th Century politics and legal reformation in Canada, the United States, the United Kingdom and the Caribbean. Their individual contributions to the West Indies Federation, Caribbean labour politics, UNIA, the Pan-African Congress and the NAACP and NSAAP are already the subject of literally dozens of scholarly papers, media accounts and books. The New York Times and The Crisis didn’t spill ink on nobodies, after all.

QMR: Is there a story (or stories) that struck you the most?

ET: I’m figuratively drowning in compelling stories. What strikes me most deeply these days isn’t the number of black alumni who blazed remarkable trails. What strikes me is how easily the university has negated their achievements.

The one incident that constantly sticks in my mind, is a picture of Dean James C. Connell dictating a letter to Dalhousie University’s President A. Stanley Mackenzie on May 3, 1918.

It would have been four months since Dr. Clement Courtney Ligoure (Med’s 1916) spent a heroic three weeks treating hundreds of Halifax Explosion casualties in that city’s North End. Dr. Ligoure had done this day and night, turning his own home into an emergency aid station, working at his own expense.

It was one week after Ligoure’s heroics that Connell wrote the Faculty Board to insist men like Ligoure should no longer be trained at Queen’s. Three weeks after that, Connell made a great show in the Senate of his intent to arrange transfers for black students to Dalhousie.

But three months later, on May 3, Connell couldn’t be bothered to ask Stanley for any consideration for his remaining black students. Whether Connell was or was not aware of his former student’s heroics is unknowable. Wittingly or otherwise, the drafting of this letter sits in my mind as singular moment of moral betrayal.

"In choosing to make its Black alumni invisible at Queen's, the University made itself invisible in the progress of Black communities around the world."

The Afro-Caribbean students who attended Queen's were, on average, highly accomplished … many had already established themselves as professionals before starting medical school as mature students. It shouldn’t have surprised us then or now that they would assume leadership positions later in life.

These students were part of a long-lived network of British West Indian “Away Men” who formed a hugely important cadre of professionals and political leaders stretching from Montreal-to-Miami and from Manchester-to-Montserrat.

This network was directly linked to key political, social and cultural leaders of the 20th Century including Marcus Garvey, W.E.B. Du Bois, Mamie Clark, Norman Manley, Dudley Thompson and Viola Desmond, among many others. Alumni

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THE LEGACY OF BLACK ALUMNI OF QMED:

INTERVIEW WITH EDWARD THOMAS like Drs. Ethelbert Lowe, Hugh Cummins and Curtis Skeete either founded or co-founded political or social organizations dedicated to racial equality. Alumni like Drs. Hubert Cezair, Alexander McKenley and Albion Chance were related to, or close friends to world-leading figures in politics, sports and culture. Alumni like Drs. Robert Bailey, C. T. Nurse, Noel Margetson, J.W. Saunders, Hopetoun Bond were hugely influential in advancing professional opportunities for black doctors.

Alumni like Drs. Frederick Holder, Alvinus Calder, George Clark, C. Holman Lovell, Simeon Hayes and Rev. Arthur Terry-Thompson were quiet catalysts who were instrumental in supporting key people and movements of global importance in civil rights, Caribbean independence, finance, culture and religious ecumenicism.

Prior to 1918, Queen’s had actually built a “fair play” reputation for itself within Canada because it was open to black medical students.

"In choosing to make its black alumni invisible at Queen's, the University made itself invisible in the progress of black communities around the globe" In so many disadvantaged communities, professional education is more than a mere vocational springboard -- it is also a ladder to public leadership. We saw this play out with many of Queen’s alumni.

Given the depth and breadth of achievements among the fifty-plus black alumni prior to 1922, it is clear that had Queen’s continued its engagements with these Caribbean students into the 1960s, it would have been an important Canadian reference point for many points of black social and economic empowerment. Not only did the university destroy its future potential to contribute to this progress, but it severed its relationship with those few who had gained important professional footholds here. In choosing to make its black alumni invisible

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at Queen’s, the University made itself invisible in the progress of black communities around the globe.

QMR: In what ways can current medical students and faculty acknowledge and remember these students?

ET: Well, the institution needs an honest reckoning with its own history. It will undoubtedly make some kind of public statement. The public rituals of atonement are important and necessary — and I fully support any such gestures— but I’m less excited by those outcomes than I am by the prospect of changing your thinking. You cannot reconcile yourself to your black Meds’ legacies if you only understand them as victims to be pitied. Their value to you is that they are superlative examples to be emulated. If future Meds’ could duplicate the standards of public service set by the 1900-1922 black alumni, then Queen’s would shock the world.

Those early black medical students were bent on using knowledge to change the world for the better. They understood exactly how a university is made meaningful in the world. If you give a damn about doing justice to these students’ legacies – then strive to contribute as much to the world in your time as they did in theirs.

QMR: What are your next steps with your research?

ET: I’m still finding new threads in these stories. I continue to catalogue and archive evidence.

This story is larger than Queen’s. I will be examining the university’s policy role in the larger context of defining and enforcing the post-War Canadian ethno-state. There is already excellent work along these lines by scholars like Hastings, Duffin and Backhouse. I’m particularly interested in the narrative tropes about black physicians in this era.

There is of course, lots of publishing work to do.

In the longer term, I’m interested in what the persistence of a false history can teach me about institutional narratives, which is another way of saying I’m interested in how institutions invent and sustain their own internal cultures.

ACROSS 1. Healer of gladiators 6. Queen's building converted to hospital during WWI (5,4) 9. 16th c. catch-all drug 10. Practice of drilling holes in a patient's skull 12. Edward used cowpox to treat smallpox 17. Ancient ointment, toxic 21. Alexander Fleming's famous discovery 22. Province inspiring Canada's national healthcare system 23. Franklin, discoverer of DNA's structure 25. Famous Queen's medical historian 26. Winter is coming 28. 2003 Epidemic 29. Banting's buddy DOWN 2. Code developed partly to enhance medical ethics, 1947 3. American hospital founded in 1889, origin of "residency" and "rounds" (5,7)

4. Ancient Egyptian physician 5. Insecticide used to combat malaria 7. 1942 Saskatchewan premier (5,7) 8. 1954, first transplant of its kind 11. The man who cured scurvy (5,4) 13. Instrument invented in 1816 by Rene Laennec 14. Greek god of medicine and healing 15. The father of medicine 16. Primitive phlebotomy tools 18. Kingston's former psychiatric institution, _________ Asylum 19. 16th c. Flemish physician detailing anatomical structures, Andreas ________ 20. Kingston-based Women's Medical College moved from this building in 1890 (4,4) 24. Before the "Queen's School of Medicine", it was colloquially known as "The _____" 27. Four bodily liquids

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CHANGES AND GROWTH D Safia Ladha, Meds'20 I remember the first day of med school like it was yesterday. I arrived with lots of excitement and anticipation, which quickly transitioned to overwhelming fear and anxiety. I remember feeling completely lost during Dr. Mackenzie’s first anatomy lecture (of many that day), where I naïvely brought a paper notebook and pen in a meek attempt to frantically capture everything he said. I remember looking around me to see most people with laptops furiously typing away in some unrecognizable program, later to be discovered as OneNote. It dawned on me that the last time I was in a traditional university classroom was 8 years ago, at a time when bringing laptops to class wasn’t much of a thing and we usually just took notes on printed slides or a collated book of notes bought from the bookstore. It took some time for me to abandon my dinosaur ways, but I got there eventually. I struggled to keep up throughout that first day and went home to my just-moved-in mess of an apartment with hours of schoolwork laid out before me. I can laugh about that daunting first day looking back on it now, but I can assure you at the time there was very little laughter.

The days stretched into weeks, and I found myself feeling out of sorts. The confident, self-assured scientist that had developed over the past 6 years of graduate school seemed to have retreated into its shell, leaving behind the insecure teenager from years past. It was a weird feeling to suddenly find myself in an utterly unfamiliar environment, longing to be socially accepted and academically comfortable again.

One could argue that these feelings shouldn’t have been so foreign to me – after all, I had transplanted my life in the name of education twice before. For some reason I felt that it was a lot easier back then. Part of me wonders if it becomes harder to adapt to new environments as we get older – that when we’re younger we have a more fearless approach to major life transitions. Or perhaps there is greater excitement in leaving home for the first time. Or maybe it’s just that the positive memories over my past 14 years of post-secondary education have prevailed over the feelings of fear and anxiety; that the happy memories stand the test of time better.

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As clerkship nears, it’s an appropriate time to reflect back on past transitions and consider what helped me get through them. The insight gained from such introspection invariably allows us to build an arsenal of coping strategies to optimize life transitions. Here are some humble thoughts based on my past experiences: - Try to come to terms with the change that is happening.

Recognize it is normal to feel fearful and anxious. Recognize the presence of such negative feelings and don’t suppress them.

Instead, grant yourself the permission to feel them. For me, it was awful for a while and I cried a lot, but gradually I felt better.

I remember also crying a lot when I first moved to Vancouver six years ago, but it became home over time and by the end I really didn’t want to leave. Be patient with yourself – adjusting to new environments takes time.

- Try to devote some time to social engagement from the beginning. Admittedly, I had a tough time with this one (orientation week felt like non-stop socializing, which is challenging for a relative introvert) but I am thankful in retrospect that I socialized to some extent as it laid the foundation for strong friendships.

- Take advantage of your support systems. These can include family, friends from back home, a religious or cultural community. I spent many hours on the phone with my partner and parents and was grateful that I had reached out to them – it is much harder and near impossible to go at it alone.

- If possible, visit your previous environment. Experts in transition theory may not agree with this one, but I found it exceptionally restorative to return to Vancouver at every possible opportunity; I still do. These trips allowed me to share my experiences with my friends back home and enjoy all of my favourite things (largely donuts and sushi).

- Maintain a sense of exploration and a willingness to experience new things. Had I ever spent time in a dragonboat before first year? Barely. Had I ever sung outside of the confines of the

Reflection

H DURING FIRST YEAR shower, let alone been part of an a capella group? Absolutely not. But through these initiatives I’ve built a network and become part of a community. We must explore and engage with our new surroundings before they can start to feel familiar.

- Try to maintain a gratitude-based approach. It’s a cliché, but it helps frame the situation positively. I continue to be extremely grateful for being geographically closer to my parents. I can reap the endless benefits of their wonderful cooking and TLC by travelling a mere 2.5 hours. I am grateful for the opportunity to pursue higher education, something for which my parents sacrificed a great deal.

One of my most effective coping strategies during moments of uncertainty is recalling this quote I stumbled upon several years ago: “Whenever you find yourself doubting how far you can go, just remember how far you have come. Remember everything you have faced, all the battles you have won, and all the fears you have overcome.” – Unknown While the medical education journey is not yet over and is sure to bring future transitions, I constantly remind myself that transitions are opportunities for learning and growth.

Retrospectively, I can confidently say that a net greatness has resulted from all of my life transitions thus far and I remain optimistic that this one will be no different.

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THE PATIENT WILL NOT SEE YOU NOW June Duong, Meds'19 An article1 about a male Asian student getting jumped was recently published in the Queen’s Journal. As I was about to go on another one of my Twitter rants, I couldn’t help but reflect on my own current situation. As a third-year Queen’s Medicine student, I’ve heard the word diversity thrown around a lot.

Our school is proud to promote and welcome diversity, and we seemingly have a student population that is more diverse than that of Queen’s at large. I don’t know the stats, but I don’t need numbers to verify how I feel walking around on campus and interacting with peers.

There’s diversity in pictures, and then real, true diversity.

Diversity doesn’t simply mean a nice photo op of people with different skin colours, but rather of people with different lived experiences. How many of our students come from low income backgrounds? How many of our students had to pay their own way through post-secondary education? How many of our students’ parents don’t have post-secondary degrees? Some of my interactions throughout medical school have made me feel truly isolated. And as someone who is privileged enough to even pursue this expensive career path, I can only imagine how some of our patients must feel when they interact with us.

Here’s a brief background to give this some context. Both of my parents are refugees from Vietnam. My mom managed to finish high school, which was an immense feat – she was the first in my family to ever get that far. My dad has never received a formal education. I spent the first 10 years of my life growing up in Driftwood, a neighbourhood in the Jane and Finch area. Our apartment had mice and/or cockroach problems, we’ve called the police on neighbours multiple times, our recesses were occasionally interrupted by code yellows and reds, and I had some questionable teachers (along with some outstanding ones). I started working for cash (“under the table”) before I was even old enough to legally work. At one point in high school, I was working 3 part-time jobs to save up for a post-secondary education I knew I wanted.

Fast forward 12 years since moving out of Driftwood, and

I was going to start making my way through a ridiculously expensive program. I had continued working for most of my undergraduate degree, so between loans, my income, and some grants/scholarships, I was pretty certain I could make it through. But there were many times when I considered abandoning this path just to ease the financial burden on myself and my family.

Thus, I embarked on this journey, wide-eyed and bushy-tailed, as they say. It was a really hard transition, not school-wise, but spirit-wise. I was told, “You will have 99 new friends!” And so, I remember promising myself to be really social and to try hard to put myself out there. Which I did. For about two months.

Then I gave up and reverted to my usual habit of keeping a small circle of friends. Don’t get me wrong, everyone is really nice and collegial and great and whatever. But it’s hard to keep up a conversation with people you have little in common with.

It is mentally exhausting.

"Ours is a system of privileged people who, for the most part, have not experienced the social determinants of health and who have enough support from their privileged colleagues that they feel no need to change their worldview.""

Let me give you an illustrative example. On one of my first days as a fellow QMed during O-Week 2015, I was sitting at a table with some other first-years. We were having a nostalgic

1. http://www.queensjournal.ca/story/2018-01-18/lifestyle/getting-jumped-at-queens-for-being-asian/

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Essay

conversation about our awesome summer camp experiences.

Except there’s a problem: I’ve never been to summer camp. My family couldn’t afford it growing up. In fact, none of the kids in my neighbourhood had been to summer camp, so I didn’t even know that this was a thing until I was a teenager. Could you imagine the revelation? “Kids get to go to a new place with a bunch of other kids and do cool things like canoeing during the summer instead of just moping around the neighbourhood?! Are you kidding me?!” So as it got to my turn, I just sat there with a stupid smile on my face.

This set the stage for many of my interactions throughout my two and a half years here. Examples include someone who admitted to me that one of their medical school application reference letters was a family friend who also happened to be a doctor, a classmate making an insensitive comment about cultural medicine that Chinese people practice, and a student council member claiming that everyone has the means to pursue expensive experiences such as overseas global health electives. I wouldn’t even dare to dream about having such prestigious personal connections. My family believes in traditional Chinese medicine. And I’ve barely travelled because of financial restrictions. If someone like me, privileged enough to even be on this path, can feel so disparaged by some of these comments, how must some of our patients feel when they’re coming to us with their problems?

I’m comforted by the direction we’re heading in. U of T introducing free MCAT courses for low income applicants, U of T having a black applicants stream, and Queen’s having recently established an Indigenous recruitment officer. But besides how we look in pictures, can we please stop pretending? We’re not nearly as diverse as we like to think. And yet we wonder why certain populations fail to present to the healthcare system as often as they should. I’ll tell you why: it’s because they feel isolated from our healthcare system. Ours is a system of privileged people who, for the most part, have not experienced the social determinants of health and who have enough support from their privileged colleagues that they feel no need to change their

worldview. So supported that they see a course such as global health as useless. “This is important, but I already know all of this,” was a common comment I heard. Trust me, you don’t.

And having medical graduates who have learned about the social determinants of health in a class they disliked is nothing like having medical graduates who have experienced said determinants. As individuals, we need to remember to check our privileges and biases at the door. As a whole, we can pat ourselves on the back for the progress we’ve made, but not without admitting that we still have a very long journey ahead of us. A journey we must embark on not only to enrich our profession by populating it with more perspectives, but also to the benefit of our patients. And that is the end goal after all, isn’t it?

"We can pat ourselves on the back for the progress we've made, but not without admitting that we still have a very long journey ahead of us."

So that 3 o’clock patient you have? You know, the “difficult” one who never checks their blood sugar levels and always forgets to do their bloodwork before the appointment? While you moan and groan about them, they’re stressing about paying for all of their medications and getting time off work to come and hear you lecture them on how they’re not doing enough.

That patient will not be seeing you now.

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