My White Coat Ceremony address to the MD Class of 2018


Good Afternoon Med 1 students here at the College of Medicine, President Barnhart and our distinguished guests who serve as cloakers, proud family and friends, colleagues. It is indeed a great honor for me to give this keynote address to my first White Coat ceremony at the College of Medicine. This profession has been an incredible privilege for me since the very first day of medical school and I am excited to further welcome you to Medicine through this ceremony.

As a community Family Doctor and as a committed introvert I must admit I was always more of a sweater and khaki’s kind of doctor. But I vividly recall my own first white coat and the excitement and anxiety of first putting it on in front of the mirror and wondering who was this doctor look alike staring back at me.

So there is little doubt that the role of the physician in society is changing. We now work in inter-professional teams, everyone’s scope of practice is changing, and the physician’s immense knowledge base is now available to everyone on their phone!

So what does it mean to be a doctor? I was interviewed on this topic just a month ago by a consultant engaged by the Canadian Medical Forum – a high level alliance amongst all of our profession’s national organizations.

I want to talk to you today of  3 aspects of the role of the physician that I discussed in that interview: privilege and the doctor-patient relationship; becoming a doctor and professionalism along the way; and the meaning you can attach to this white coat.

By privilege I don’t mean the entitlement that comes from success or pride. In fact I mean the opposite. What I am talking about is the immense privilege we receive when our patients demonstrate their trust as they enter into the doctor-patient relationship with us.  There is a social contract between society and our profession that confers on us great benefits like profession-led regulation, autonomy and substantial personal reward and society expects in return when they are ill or vulnerable in any way we, either individually or collectively, will always act in their best interest.

I have a story from my own practice. Colin, an eighteen year old guy, ran his motorcycle into a moose one night and in an instant became a quadriplegic. His bright young girlfriend, Cathy, stuck by his side and when he left the hospital a year later they married. After that as a very young man I became their family doctor and we embarked on a remarkable 20 year journey together. Life dealt them and thus me many interesting challenges. What always amazed me was the humor and resilience they always demonstrated and the remarkable trust they showed in including me on that journey. She had obesity and early type 2 diabetes  and he had frequent UTI’s and many hospitalizations for pneumonia. Along the way I delivered two daughters one of who developed chronic kidney disease. They always visited together and every challenge was met with met with a smile or a joke.

One day they came in laughing and said have we got a story for you. As their kids grew they had got into a habit of going for a ride in their van whenever a serious family matter arose. On this occasion he said we should go for a drive and she responded that coincidentally she had something to tell him. They said Preston you are not going to believe this! First he told her their 16-year-old daughter was pregnant and then she told him their 15-year-old daughter was pregnant! And then they laughed! I was in shock but — what else were they going to do! And so I laughed too!

Looking back I am still in awe of the fact they trusted me enough not to judge and that I would be there for them through another of the unending trials life would throw at them.  I got to deliver those two babies and of course one of them developed chronic kidney disease.

This rich and unique doctor-patient relationship is to me one of the most important aspects of being a physician and always must be cherished.

Before I talk of professionalism in medical school I want to emphasize one unique aspect of our  profession.  Only physicians have both the immense breadth and depth of knowledge about the human condition and the tremendous toolkit, along with our colleagues and partners in the healthcare system, to help people in need. Doctors span genetics to geriatrics, renal physiology to population health, talk therapy to endovascular treatment of brain aneurysms, and the list goes on.

Professionalism is the second aspect of our role and essential to how we apply that knowledge and toolkit. I have another story. Last week a frustrated faculty member was telling me of a fourth year student. This student was at rounds with the healthcare team, sprawled across a chair with feet up on a desk and started his case presentation with the words: “This patient says….”. This is one of those “count how many things are wrong in this picture”. First even the most casual amongst might perceive little respect, second the patient does not have a name and finally the patient’s story is considered suspect.  Certainly not a stellar demonstration of professionalism.

But that is not what worries me the most. When challenged the student’s explanation was that he was going into radiology and not much interested in internal medicine.  I don’t know how you do radiology without immense knowledge of internal medicine but that is another discussion.  Professionalism requires respect:  respect for the knowledge you have learned, respect and understanding for how much you still have left to learn, and above all:  respect for your patients and colleagues.

Before I pass on my next piece of advice to you I would like to share some statistics. I know you are already thinking of CaRMS and our system seems biased to making you choose a specialty before even becoming a doctor. One third of you come to medical school with a firm fixed belief of your chosen field. I think a few of you can even trace this back to the seventh month of your gestation. One third of you have a good idea of what you want to be and one third of you have no idea! The important statistic is fully one half of those with an idea or a firm fixed belief will change your mind while in medical school.

So my plea to you is this:  medical school is your only chance to first become a doctor. No matter your field that breadth and depth of knowledge of the human condition is essential for every doctor-patient relationship. Keep an open mind, take it all in and first become a doctor.

So what does this white coat symbolize to me? Remember, I’ve always been a sweater and khakis doctor.  When I first went back to Dalhousie as a full time faculty member I was amazed.  The first day in the hospital I saw a senior colleague in a white coat with 6 white-coated students following in a line closely behind. I must admit being tempted to follow along, just to see if they really would follow him right into the bathroom!

Seriously this is important because some have criticized the white coat and white coat ceremonies as symbolic of entitlement and elitism. I choose to view it as a symbol of altruism. Altruism is defined as the selfless concern for the well being of others. It is a key component of the Hippocratic oath. Heroic examples abound such as the famous Canadian Norman Bethune in Spain and China who was a friend of the first dean of this college, Dr. Wendell MacLeod.  Today I think of all those health colleagues now in Africa fighting the Ebola epidemic. I don’t ask for heroism everyday but what I do ask for everyday is you always put your patients needs first.

This word privilege is interesting. Just over 100 years ago doctors were in private practice and the hospitals were for the poor and the patient faced less than even odds of benefit from approaching either doctor or hospital.  But as medicine advanced doctors needed the hospitals to help their patients and thus applied to work in the hospital. That was and still is called “hospital privileges”. So patients give us their trust and the healthcare system gives us privileges. This trust and those privileges are dependent on us putting the patient first.

As I said on your first day you are now in a new learning dynamic where the patient is as integral and essential to your education as your professors. Over the next 4 years your patients will be paying it forward in teaching you. They will be your very best teachers.  Cherish the doctor-patient relationship, embrace and practice professionalism and remember the meaning behind privilege.

So for me wearing the white coat as a learner symbolizes what we owe our patients.  And for me as a physician it is a symbol of the immense privilege we have in this profession and the trust we receive every day in every unique doctor-patient relationship.

So I wish you all the best in your journey here at the College of Medicine. I look forward to learning alongside and from you.  Remember my door is always open and I want to hear from you. And think often of the great privilege you have have been given in this profession of helping people through the doctor-patient relationship.





Why Distributed Medical Education

This summer I have had the chance to tour this beautiful province and to date I have been to 6 of the health regions.  I have met committed physicians, hard working hospital and community leaders and enthusiastic learners. I have also learned of the challenges with the longstanding shortage of doctors in Saskatchewan. It has reinforced to me why we must get distributed medical education right for the people of Saskatchewan. I will start with 3 anecdotes that align with the 3 principal reasons for distributed medical education that are evidence-based. Continue reading

I’m being called ‘relentless and flexible”

To be sure, the new dean of medicine at the U of S sees many changes on the horizon for the college but Dr. Preston Smith wonders if there is a group of professionals better prepared for change than doctors.

“Our faculty members don’t treat heart failure the same way as in the past; they fully expect the medicine they practice to be as cutting edge and evidence based as possible, and the medicine we teach should be as well.”

Because medical knowledge and research changes so quickly, so too should the schools teaching it, said Smith who stepped into a five-year term as dean June 1, adding he is ready for the challenges and changes that come with his new role.

“There are a lot of drivers for change in medical education, said Smith. “Accreditation is one. Student success on the medical council exams is another. The final thing is Canadian Residency Matching Service competition, and our students’ ability to compete for residency spots across the country. That’s all about the clinical skills.”

But for Smith, it comes down to how fast medical knowledge changes and grows.

“The body of knowledge over time has grown exponentially and so has the curriculum,” explained Smith, who most recently held the position of senior associate dean of education at Dalhousie University’s Faculty of Medicine. “The estimate by some is that the medical database, in terms of research and new information, is doubling every three years.”

In order to keep pace and to address longstanding structural issues that landed the U of S college on probation with the Committee on Accreditation of Canadian Medical Schools, a vision implementation plan called The Way Forward, was created. Turning plan to reality is Smith’s immediate priority.

“We must be relentless and flexible as we move forward in implementing our strategic plan. The Way Forward is the entire basis of what we are going to do to change the College of Medicine, get off probation and start becoming a highly competitive research operation,” said Smith, who worked on similar issues at Dalhousie to those faced by the U of S.

“I am certainly at an age and stage in my career that I thought I was ready for this challenge. The job I had at Dal for the last five years was a second-in-command role and we did a lot of similar things that need to be done here,” he said. “That’s why I think I have the experience needed here.”

On the research front, the College of Medicine has been underperforming for sometime, and the faculty complement requires a reconfiguration to put more emphasis on clinician scientists, he explained.

“That’s not to take away from existing faculty… but if you look across the country, the places that are really successful have a core of physician researchers working collaboratively with the basic science researchers.”

The first step towards increased research productivity is to recruit a vice-dean of research who is “truly a leader in that arena.” The vice-dean will lead the development of a strategic plan for research with the goal of creating a core of “clinician scientists, doctors and biomedical scientists who work together.”

But the U of S college restructuring goes beyond research with an additional focus on medical education.

“There used to be a culture in medicine that as long as you were a doctor you could be a teacher, but now there is growing body of understanding and evidence that training a doctor is a complex process,” said Smith, whose background is in medical education. “The Way Forward commits us to hiring more faculty members who are experts in medical education. That’s a big step forward and aligned with my interest and values.”

Hand-in-hand with recruiting more medical educators is a revamp of the curriculum—specifically moving to what is known as 2+2 curriculum with two years of pre-clinical training followed by two years of clinical training. The old curriculum included about two-and-ahalf years of pre-clinical and one-and-a-half years of clinical work for medical students.

“The emphasis on getting more and more clinical knowledge into medical school is why we’re a moving to this curriculum.”

The curriculum change will better prepare students for the Medical Council of Canada exams. “These exams have an increased emphasis on practical clinical knowledge and the ability to apply it as opposed to recite knowledge from a textbook. So if that’s where the exam is going, then our curriculum had better be going that direction as well.” All of these changes will take time, but in the big picture, Smith likes what he sees.

“We will be off probation, there is no doubt in my mind. Our College of Medicine will be known for serving its community, the entire province of Saskatchewan, better than any other Canadian medical school. That means we train the right doctors for the right communities and we have innovative research programs that bring in external research dollars, which drives the economy. When people in Saskatchewan read about us in the paper, they will take pride in the accomplishments of our medical school.”

Article written by Kris Foster.  Originally published in OCN