The clinical teaching unit is a widely-used clinical training model that requires reform to prepare physicians for practice in the 21st century.
In a systematic review in CMAJ, Dr. Brandon Tang and co-authors identified practices in internal medicine clinical teaching units that contribute to improved clinical education and health care delivery.
Dr. Tang, a PGY4 in general internal medicine at the University of Toronto, speaks with Drs. Blair Bigham and Mojola Omole about the findings of the review, his experience with CTUs, what inspired him to look into the research, and his thoughts on how CTUs can be reimagined to improve both learner and patient outcomes.
Drs. Bigham and Omole then speak with Dr. Lisa Richardson, a clinician-educator in the U of T’s Division of General Internal Medicine, about other aspects of medical training that are due for a rethink.
Dr. Richardson, who also practices at the University Health Network and is an Education Researcher at the Wilson Centre, argues that medical training needs to create space for learners to bring their whole selves to their educational experience, rather than struggle to conform to a narrower sense of what it means to be a physician.
CMAJ is the journal of the Canadian Medical Association.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
The clinical teaching unit is a widely-used clinical training model that requires reform to prepare physicians for practice in the 21st century.
In a systematic review in CMAJ, Dr. Brandon Tang and co-authors identified practices in internal medicine clinical teaching units that contribute to improved clinical education and health care delivery.
Dr. Tang, a PGY4 in general internal medicine at the University of Toronto, speaks with Drs. Blair Bigham and Mojola Omole about the findings of the review, his experience with CTUs, what inspired him to look into the research, and his thoughts on how CTUs can be reimagined to improve both learner and patient outcomes.
Drs. Bigham and Omole then speak with Dr. Lisa Richardson, a clinician-educator in the U of T’s Division of General Internal Medicine, about other aspects of medical training that are due for a rethink.
Dr. Richardson, who also practices at the University Health Network and is an Education Researcher at the Wilson Centre, argues that medical training needs to create space for learners to bring their whole selves to their educational experience, rather than struggle to conform to a narrower sense of what it means to be a physician.
CMAJ is the journal of the Canadian Medical Association.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Mojola Omole:
Hi, I'm Mojola Omole.
Dr. Blair Bigham:
And I'm Blair Bigham, and this is the CMAJ Podcast.
Dr. Mojola Omole:
So, this week we have a really interesting topic dealing with medical education. We're talking about the clinical teaching unit on Internal Medicine and an interesting paper that was recently published in CMAJ, looking at how to rethink and restructure these clinical teaching units. Blair, when you go back to your experience a long time ago as a medical student and a resident, what's the first thing that comes to mind when you think about the CTU?
Dr. Blair Bigham:
Come on Jola, it wasn't that long ago.
Dr. Mojola Omole:
Okay. It's so much longer for me.
Dr. Blair Bigham:
The CTU, wow. That was a block that was intimidating. You sort of had a bit of anxiety coming up to your Internal Medicine block. Especially as an emergency doctor, I think we have this inferiority complex, we think we don't have all the smarts needed to run an Internal Medicine ward. And certainly going into that CTU experience was a little bit daunting because even things that, I mean, sound simple that you learn in medical school, like what your HDL and LDL targets are like I, as an emergency doctor that wasn't front of mind in my first year of residency.
Dr. Blair Bigham:
So, I found the CTU a little bit intimidating and also found it a little bit odd how I would get these different patient assignments and they didn't really seem to match what I was hoping to learn on CTU. So, there's lots and lots of awesome medicine cases that emergency doctors want to learn more about. But sometimes there was a bit of a mismatch. And so, I didn't always feel fully engaged. For me, the CTU was just, it was really hard.
Dr. Mojola Omole:
I did it as a medical student. I didn't have to do it as a resident. And I found that it was long. The days were long. There was a lot of service and I didn't always feel connected to the didactic lectures that we were having at the same time. But I do think that this paper really brings up some interesting ideas for medical education that could have some broad application to other specialties.
Dr. Blair Bigham:
So, let's jump right into our first interview and find out how we can make the CTU more engaging, not only for Internal Medicine trainees but for all of us. Dr. Brandon Tang is a PGY-4 in General Internal Medicine at the University of Toronto. He's also the lead author of the systematic review of clinical teaching units published in CMAJ. Hey Brandon.
Dr. Brandon Tang:
Hey Blair. Thanks so much for having me.
Dr. Blair Bigham:
No problem. Thanks for joining us. So, you're a PGY-4 right now in General Internal Medicine. So, the CTU is a big part of your life. How much time do you spend on the CTU?
Dr. Brandon Tang:
More than I'd like to admit. I think the past three years it feels like I've lived there. It's where we spend most of our time as core Internal Medicine trainees, and this year, maybe only a fraction of my time, but in the future as an aspiring academic general internist, that's again where I'll be spending most of my time as a general internist.
Dr. Blair Bigham:
So, having spent so much time on a CTU and having authored this study, is there anything that kind of jumps out at you as being a bit of an odd thing that we do right now on the CTU?
Dr. Brandon Tang:
Yeah, great question. This idea of CTU design is something I've been thinking about since med school, actually. So, it was a really exciting study to finally complete. One thing that stood out to all of us was that a lot of the findings were pretty low hanging fruit or things that are pretty easy to implement like even today or tomorrow, things like purposeful rounds or just thinking thoughtfully about the order in which you're going to see your patients, geographic wards, grouping your patients in a single area. These were all pretty high impact interventions that are pretty easy to implement. And when we were working on this, we thought that some of these findings were potentially quite obvious, but even in the last three, four days since we published a study, people have been emailing us, reaching out to say like, they wish that they were able to have some of these interventions in their centers. So, clearly there's not a consensus about the way we do CTUs across Canada.
Dr. Blair Bigham:
Interesting. And you just mentioned purposeful roundings which you also mentioned in the systematic review. Tell me a little bit more about how that differs from maybe the rounds that I experienced in residency.
Dr. Brandon Tang:
For sure. I think the idea of purposeful rounds is that at some point the team decides thoughtfully the order in which you're going to see your patients and a lot of teams do this. I remember when I was in training, you would have your senior resident or attending say, "Oh, we should see this person first. They're going to be discharged or this person's quite sick." But that was almost a thing you did naturally just because you felt it was important. But some of the studies that we identified found that teams that employed this compared to teams that didn't, actually had improved patient outcomes such as length of stay.
Dr. Blair Bigham:
Got you. Okay. I think we did do that when I was in residency. And just help me go back in time a little bit, give me a primer on sort of the history of the CTU. How has it changed over the last five or six decades?
Dr. Brandon Tang:
I think the short answer is that perhaps it hasn't changed all that much, which is why we did this study. So, the idea of CTU first arose in the 1960s in Canada. It actually came from Canadian educators in the Royal College of Physicians and Surgeons of Canada. And the original purpose was to select educationally appropriate patients for learners and I think that's a really important point which I can return to. And then there was a limited amount of teaching staff at that time. So, another mission was to try and organize these learners efficiently around a limited number of teachers. So, then this idea of graduate responsibility and the traditional structure that we know with attending physician, a senior resident, couple junior residents, some medical students, that seemed to arise pretty early. And while this idea came in the 1960s now in the 2020s, it really seemed like a lot of the things that they came up with then are just what we're doing now.
Dr. Brandon Tang:
So, that's why we tried to do this study to have a bit of direction and sort of take stock about where we are, what has been done and what we should be doing in the future.
Dr. Blair Bigham:
Is there anything sort of historical that we just continue to do that you found is actually maybe detrimental to the learning experience, things that we should just stop doing sooner rather than later?
Dr. Brandon Tang:
It's a bit of an area of controversy even in the study, but I think bedside rounds are contentious because when you look at the books, when you hear about William Osler, that's the way they did it. He took the students around, they saw all the patients, they examined their hands and looked at all these interesting things. We romanticize that period. A lot of learners today thought in our study as well found that it's a bit of potentially inefficient way of connecting grounds, although patients and attending physicians tend to view it as more patient-centric which was also a finding of the study. It seems like it depends on which perspective you take. Patients and attending seem to think it's very patient-centric. The learners who are facing the pressure of the system seem to feel that it's inefficient and perhaps gets in the way of patient care.
Dr. Blair Bigham:
And so, do they find table rounds more efficient, or what's the alternative to bedside round?
Dr. Brandon Tang:
So, some of the alternatives include maybe a hybrid model where you do table rounds, you discuss the patients in another setting. And then afterwards you could go into the patient's room with the team and discuss the plan with them. And I think that is probably the approach I'd favor in certain situations. After our review was published, they actually did a randomized control trial on bedside rounds in Switzerland. It wasn't included in our study because it was after the search date, and they pretty much found that patients liked bedside rounds. They liked having that time with the whole team there, but they were actually more confused by having the team use all the medical jargon and go through everything in front of the patient. So, to me it emphasized what a lot of learners have been feeling that perhaps some of the medical decision making and jargon is best had outside of the room, but then you can still have that patient-centeredness by going in as a team to discuss the plan with the patient, get their input.
Dr. Blair Bigham:
I find it so interesting that attendings seem to favor bedside rounds in your review, but residents don't, and you bring up the word efficiency a lot. I think we talk a lot about service-to-education ratio and sort of being so busy that you don't have time to learn. I always found that bedside rounds is like where things started to click, right? You would see that physical finding or you would hear that heart sound and be like, "Oh." So, I always found them really worth the time. What do you think is in the system now that makes bedside rounds sort of less valuable for learners?
Dr. Brandon Tang:
So, there's a couple things to unpack there. The different perspectives between staff and residents and the differences in the healthcare system now makes it more challenging. One of the findings in our review was that essentially the more patients you have, the more work you have, the less time you spend on education and people were less likely to do bedside rounds when they were busier clinically. So, I think that kind of has a bit of the answer. Bedside rounds do take longer just the physical aspect of walking around to see all the patients, bringing the charts along, the whole team, talking to the patient, examining the patient, those things intrinsically take time although they do have educational value. But when you're in a system where people are already feeling overworked, burnt out, what have you, it seems like learners start to feel that it's not necessarily educational, they just want to get on with it because they have a million other tasks to do to look after the patients.
Dr. Blair Bigham:
Right. And I want to get into this a little bit deeper because I think there's sort of some golden nuggets in here. Because there's this traditional argument of the more hours you work, the more patients you see, the higher volumes you process, the more you'll learn through experience. And then often learners will say, "But then I don't have time to read around my cases. I don't have time to study. I don't have time to practice." Where's the balance come down in a CTU so that learners are busy enough and stressed enough that they're engaged and experiencing sort of the practice of medicine, but not so stressed and so overloaded that it becomes detrimental to their progression?
Dr. Brandon Tang:
I think you hit on this idea of deliberate practice where you want things to be just right in terms of the degree of challenge. So, starting off with this narrative of the tension between patient care and education. I think that it's a little bit artificial, but there's also a little bit of truth to it. People feel like there's patient care tasks, writing discharge summaries, writing notes, that sort of thing. And then learners often distinguish that from educational tasks which are sitting in a room, learning from a whiteboard talk or listening to a PowerPoint presentation. And I think that the idea of CTU is that you can try and bring those together. So, the unique education or clinical education comes from your looking after patients, you're trying to apply this theoretical knowledge you have to make decisions which are guided by the team.
Dr. Brandon Tang:
However, I think a lot of that comes from when you have time and space and energy to do this sort of shared analysis or thinking classically being when you're sitting in rounds, you're presenting your plan and the attending kind of asks these questions to probe your thinking and walk you through it. I think that's where the real unique clinical learning happens on the CTU. However, I think that, in the current situation, I talked about this idea of selecting educationally-appropriate patients when we have no controls on volume or no controls on complexity, suddenly you are losing the ability to slow down and go through this careful thoughtful process with learners, which is where I think the true learning happens.
Dr. Blair Bigham:
That's a great point. Can you tell me a little bit about the patient perspective on all of this? You mentioned that patients like bedside rounds, They can also get a little bit confused by the sidebar conversations that go on around them. Are there any tips for people who design CTUs that lead not only to a better learning experience but also to better patient outcomes?
Dr. Brandon Tang:
A lot of the patient outcomes in our study included things like length of stay, readmissions, mortality. So, certainly those are important patient outcomes, but I think it's different than what a patient would tell you, if you ask them, like in your teaching environment what do you prioritize? I think that at least in my experience, speaking to my patients about what works for them, they value the collaboration and communication aspects the most. I do think that a lot of bedside rounds is a method where you can achieve that where they really feel like they're being cared for, looked after by this group of 10 doctors. But I do think that when you have a well-oiled CTU where the learners are well directed, they feel empowered to look after their patients. They have time to speak to their patients where they're not being constantly interrupted by a million pages. When you have all of the other things in place, the patients will get better care and they'll feel that.
Dr. Brandon Tang:
So, thinking about my own experiences on the days where I have 10 patients as a junior resident, I'll rush. I'm trying to get out of that room so I can write the note, write the orders, write the discharge summary. But when you have time, you're more likely to build that rapport, make observations and I think the patients feel like on those slower days that they're getting better care.
Dr. Mojola Omole:
If you can do one thing right now to improve the CTU in terms of medical learning and providing high quality patient care, what would it be?
Dr. Brandon Tang:
I think the most impactful intervention to redesigned the CTU would be creating a system to filter appropriate volume and complexity for patients that learners will look after, because the way it works right now is, at a teaching hospital, whoever shows up in that emergency department and needs to be admitted to, say, Medicine, which is the focus of our study, that's who's going to end up on the CTU. If this person becomes ALC and they can't leave for one to two months, oftentimes there's not another place for them to go and they remain on the teaching unit. So, I think that having a system where we can control volumes, which I think could be through non-teaching teams, it could be through physician extenders and also complexity. So, ensuring that there are patients who are somewhat medically active, ensuring that there are patients who have the appropriate amount of complexity which could be through potentially targeted-level CTU teams, or potentially offloading like non-active patients to non-teaching teams. So, controlling volume complexity, I think, is the key for a better learning environment, which I also think would be better patient care for teaching teams.
Dr. Blair Bigham:
Kind of extending that idea of purposeful rounding to a purposeful CTU census.
Dr. Brandon Tang:
I think that's great. Yeah. Great way of putting it.
Dr. Blair Bigham:
Brandon, this has been superb. I hope we have a lot of program directors listening to our podcast today who are having similar thoughts to you about how we can design a better learning and patient care experience on the CTU. Do you think a lot of this applies outside of the Internal Medicine CTU, do you think this applies to other specialties as well?
Dr. Brandon Tang:
100%. In the last three days, colleagues from neurology and pediatrics so far have asked about the other parts of our data from other specialties. So, there's definitely an interest in thinking about how we can optimize our teaching environments in a range of medical specialties. So, we're really hoping that this study, this podcast, triggers our broader conversation and investigation into this kind of work.
Dr. Blair Bigham:
Awesome. Well, as a current fellow and a former resident, thank you so much for doing this. I think as you said, it's been 60 or 70 years of more or less the same model and our system's changed a lot in that time.
Dr. Brandon Tang:
Yeah. Jola, Blair, thank you. It's been a pleasure. Thanks for having me.
Dr. Blair Bigham:
Brandon Tang is the PGY-4 in General Internal Medicine at the University of Toronto and the author of a systematic review of evidence-based practices for clinical education and healthcare delivery in the clinical teaching unit, recently published in CMHA.
Dr. Mojola Omole:
Brandon's focus on the CTU givs just a sense of where to start reforming medical education. But how about when we go beyond the CTU? What other aspects of medical training are due for us to rethink? Dr. Lisa Richardson is a clinician educator at U of T's Division of General Internal Medicine at the Toronto General Hospital. She practices at the University Health Network and is an education researcher at the Wilson Center. Thank you very much for joining us today, Dr. Richardson. So, Brandon says his interest in reforming the CTUs comes from his experience when he was a medical student and also now as a resident working within them and noticing that certain things just didn't make sense to him. When did you begin to question the way we educate physicians or would-be physicians?
Dr. Lisa Richardson:
Probably as soon as I started my Internal Medicine residency training. I was quickly immersed in that CTU experience, working extremely long hours. I actually became pregnant several months into my internship. And so, I was literally doing a 100 hour work-weeks with call while also trying to care for myself during my pregnancy and then coming back with a young baby and being a senior resident doing 36 hour call shifts. Things have changed a little bit since then, but I clearly realized then that this experience felt dehumanizing for me and made it difficult to provide humane and patient centric care for all of those I was looking after.
Dr. Mojola Omole:
And what would you say is missing from the medical curriculum that makes it dehumanizing?
Dr. Lisa Richardson:
The reality of when one becomes a physician is that you put on the white coat and your whole identity is subsumed by it. Our backgrounds, our lived experiences, our concerns about what's happening in the world are all expected to be gone. They vanish and we have to practice in this particular way which is a way of being a practitioner, a doctor, that has been around for a long, long time - but in reality is quite an exclusive one. So, when we're talking about being a person who has a different background than the usual people who are going to medical school for hundreds of years, all of those experiences are gone and it leads to this disconnection in who you are as a practitioner.
Dr. Mojola Omole:
And if you were to think about how to re-imagine, basically creating a holistic environment for medical education, what do you think are some of the system changes that have to happen?
Dr. Lisa Richardson:
So, when I think about the clinical teaching unit, the beauty of that model when it first evolved was actually understanding how intricately linked patient care and the education of future physicians and future specialists, future practitioners, is. The problem is that, due to the external forces that Brandon and the team talks about in the paper, the system has grown, there are more and more patients, and yet we still were not able to preserve the educational experience in that. Because, when you're moving quickly, you're trying to see many patients, you're spending a lot of time documenting on the computer, et cetera, you lose track of that important relationship with the patient of learning and everything that one can learn from that. And the thing that sort of, that really struck me in the review is the fact that all of the interventions that we've studied are about these process issues that really don't consider the experiences of our patients.
Dr. Lisa Richardson:
There's like the bedside rounding was seen to be very beneficial for patients and attending physicians because of the improved patient and communication between doctor and patient, but that was seen to be not as well-liked by the residents. And so, how do we actually understand that those needs must be intertwined and how do we understand that we need to create access to care? We need to create learning experiences for residents outside of the clinical teaching unit in community settings, in those non-protected settings as well because the clinical teaching unit, in the way we're redesigning them, is this very well-protected, well-supported unit, but it's not the reality often of what practitioners see out on the ground with not having access to resources, advocating for shelter beds or other supports for our patients.
Dr. Lisa Richardson:
So, how do we recognize that there is a need for that as well? There's that hardcore immersive experience of Internal Medicine that happens on the clinical teaching unit in this redesigned, reimagined way. But also when I bring residents onto the reserve with me, or out into community practicing in Aboriginal Health Access Centre, the experience is deeply transformative for them. And so, how do we build those in too?
Dr. Mojola Omole:
Can you explain that to me a bit more? What’s some of the feedback you've gotten from the students about that experience?
Dr. Lisa Richardson:
So recently, for example, I was doing a lot of vaccine work outside of the hospital setting, obviously because we know for harder to reach communities, taking vaccines right to people is an ideal practice. And so, I have a fourth year Internal Medicine resident who's a chief medical resident, has excelled through our program, who said, "Wow, I wish I had done this three years ago." Because I am seeing now when I prescribe that wound care that my patient needs, when I'm prescribing the latest heart failure regimen for my patient and then I see them living in this setting or I see the circumstances under which they're having to day-to-day survive, I realize that I've missed the boat. So, understanding the particular context of the patient is so important and we can become so protected and sheltered to really focus on the differential diagnosis for hyponatremia in our patients on the clinical teaching unit that we're missing this big picture which is as referred to in the paper, which are the external forces that are affecting not just the system but that are affecting our communities and our patients.
Dr. Mojola Omole:
So, it almost feels as if what you talked about earlier about us physicians, that when we put on the white coat we're no longer humans, we're not full humans, we are doctors, which is a different class…it almost feels as if our patients, when they're in the hospital, we also just view them as a disease process and not fully as everything wholistically what's happening around them, which might explain why the students did not find bedside rounding to be beneficial because they haven't been taught to see what you're experiencing with your students and your residents, seeing the patient, like seeing the person and then seeing the patient.
Dr. Lisa Richardson:
I totally agree, and it's very interesting how those ways of interacting with our patients actually become embedded in the culture of the way we practice. And I talk about when the diagnosis becomes the metaphor for the patient. If you work on a team with me, that does not happen. We do not call someone a COPD orwe do not call someone “the pneumonia guy”. We actually speak like this. So, it's reinforced, just that example that you're giving around how the person becomes the disease. It's reinforced even in the language that we use, the way we speak about our patients, how do we actually push people through dialogue through the questions that we ask as educators to recognize that this person in front of us has much more going on than just what was documented in the history of presenting illness? So, how do we find those? How do we incorporate that into our teaching?
Dr. Blair Bigham:
Is the answer to that to build more time for those types of conversations? I feel like this is conjuring up moments in the emergency department for me where we're so busy trying to deal with volume, that we do reduce every patient down to just their diagnosis just so that we can survive. When you have a CTU team with a list of 35 patients on it, it does become overwhelming. And Brandon was talking about sort of having these teaching units, but also then making sure they're appropriately resourced. And, at the end of the day, does this come down to having non-teaching units, putting patients on attending only teams or teams with physician extenders? How do we actually achieve this balance so that learners have the time to truly understand their patients?
Dr. Lisa Richardson:
Yeah, we absolutely need to have, and most of our centers do have, non-CTU programs to actually care for patients, but we need to build that up further clearly. Having time is important. But, Blair, I also often challenge the idea of time because I say that you can have a very short interaction with someone. And I certainly have been on the receiving end where you feel seen, you feel heard, and it's not necessarily about time, it's about the stance that you bring into the interaction. Are you coming in with humanity and compassion? Are you attending to their comfort in the moment? What is your demeanor? Are you noticing things in the room? It's really about being present as well in the interactions. And I think that we, because I often hear that, "Oh, there's no time." I used to have a portfolio called person-centered care education and people would say, "Oh, there's no time for that." Yes, there's time. In a 30 second interaction, you can feel really good about meeting someone or you can quickly feel diminished as a human being.
Dr. Mojola Omole:
Did you find that, during your training, that perspective that you have of bringing your background and Indigeneity into the conversation, was that stripped away and you had to regain it, or were you able to kind of hang onto it throughout your training?
Dr. Lisa Richardson:
I'm only now starting to speak about my training experience because I realize it was a really difficult one. And I finished training in 2008 so that was a long time ago. And it was difficult, I think, because of the former, because I was expected to be a certain way and I felt like I had to bury myself. And I understand that now, that sense of not quite belonging which was really painful at the time - really, really, really hard. I see that now as a strength. I see how not only what I learned from that, but how I managed to remain a critical thinker and practitioner because of that liminal position that I inhabited.
Dr. Blair Bigham:
Lisa, can you give us your one or two top tips for how to live that ideal as a resident on a clinical teaching unit when you're feeling overwhelmed, when you're feeling under pressure like so many of us are these days, do you have any good tips that help us ground ourselves in that humanistic goal?
Dr. Lisa Richardson:
One of the best tips was given to me by a spiritual care practitioner... And they said to me, every time you go in to a patient's room and you do your hand washing, you pump that hand sanitizer, or now you're putting on all your PPE, take it as a moment to ground yourself, take that break, take a breath and recognize that you're going in to a new experience and with a different patient and you want to be present. Wow. That's like a tiny tip that I have carried with me that I absolutely love. It's a moment to actually focus on you and focus on the moment and recognize that you're going into a new encounter and you need to be there. So, that is one piece I really love and then the second is to cultivate a habit of knowing how you're feeling and understanding when you're feeling overwhelmed and taking the pause when you need to. Imagine that we go and we resuscitate a patient, we're giving huge news to patients about an advanced cancer diagnosis or something else that's very intense.
Dr. Lisa Richardson:
And we want to, we've done that, we've given our heart and our mind to it and done it in a good way, but then we walk away and we’re expected just to walk into the next patient and be whole. Recognize that when that happens, take a pause. Whenever something difficult has happened with one of my patients, if there's a learner involved, I will say, "We need to pause right now. It's 10 minutes or whatever, but I want to get us a cup of tea and just decompress." And that I have found to be really helpful as a practical tip as well.
Dr. Blair Bigham:
Amazing. This has been very inspiring. Thank you so much for making time.
Dr. Mojola Omole:
Thank you very much for being part of this.
Dr. Lisa Richardson:
The two of you are so deeply inspiring to me. So, thank you for doing this program and for all the incredible work you're both doing, it's really, really inspiring.
Dr. Blair Bigham:
Wow. That means so much.
Dr. Mojola Omole:
Thank you.
Dr. Blair Bigham:
Dr. Lisa Richardson is a clinician educator in U of T's Division of General Internal Medicine. She practices at the University Health Network and is an education researcher at the Wilson Center. She joined us on the road.
Dr. Blair Bigham:
Jola, I feel like we just got schooled in much more than how to run a CTU.
Dr. Mojola Omole:
I know. I think that what I found really fascinating was that the paper found that residents and learners did not like the bedside rounding, but patients really liked it. Dr. Richardson was able to really explain that in the sense of when we are no longer viewing the medical system holistically, we don't get the satisfaction out of those interactions. When we take the humanity out of the clinical teaching unit, or just the healthcare system itself, the detriment that happens to both us as practitioners and also to our patients.
Dr. Blair Bigham:
Absolutely. And it reminds me of the time I had a kidney stone and ended up in the hospital.
Dr. Mojola Omole:
Sorry to hear that.
Dr. Blair Bigham:
I've never been in that much pain in my life, Jola. And the only person that I remember from that interaction is the Porter who wheeled me to ultrasound, because he called me by my name, he introduced himself, he told me a joke. And it was those qualities that Lisa was talking about, about being present, being authentic and having sort of that whole package, not just saying the right words, but being there in the moment, fully, that really made a difference for me that day. And I just, I wonder how much of this really does come down to the perception learners have that there's just so much to do that they don't have time to be present, or maybe it's just that we haven't been taught how to be present. Maybe this is just one more piece of the curriculum that we could learn so that we can bring all of those extra qualities to the experience of a patient, without having to worry about taking extra time to achieve it.
Dr. Mojola Omole:
I think that we haven't been taught how to be present. We've been asked not to be present. We've been asked not to think about whether you have a sick dog at home, whether your car needs to be repaired. That's your problem to figure out, when and where to get that car fixed. So, in a way if you strip us of our personhood, of course, we're going to also strip our patients of their personhood. And I do think that part of what Brandon had talked about, about reducing the size of the teams and making it more manageable, so, learners could feel like, "Okay, I want to do this and I have the time to do this." So, I think it's a bit of both modeling and teaching us how to be present and how to maintain our humanity and our patients' humanity, and also creating the space that's needed for that.
Dr. Blair Bigham:
And I think like Lisa said, it brings more joy to us as well. One of my favorite things to do in the ER when people bring a book to read because they know there's going to be a wait, is to say, "What are you reading?" And have a quick 30 second chat about whatever novel they have in their hand. That's a fun little break from the medicine for me and I think gives me a little bit of satisfaction in what could otherwise be sometimes a pretty hectic and miserable day.
Dr. Mojola Omole:
I find the same thing too like in what I'm doing, seeing patients with regard to breast disease and breast cancer is, living in Toronto and Scarborough, it's quite diverse. And so, asking them about their cultural background about what's their favorite dish from where they're from and just finding out a little bit more about what their family structure and what their life structure is, it informs parts of their treatment, but also just to create an understanding that I see them as not just this diagnosis, but the rest of them. This has been a great episode with lots to think about and really practical tips to apply to my practice and I hope everyone finds it the same.
Dr. Blair Bigham:
That's it for this week on the CMAJ Podcast. Be sure to share our podcast and rate it wherever you download your podcasts.
Dr. Mojola Omole:
Until next time, be well.