LICs and the Double A MC

In mid-November, I attended the American Association of Medical Colleges annual meeting known as “Learn, Serve, Lead 2014” in Chicago. It was my first trip to both the “Double A MC” and Chicago – what a lovely and fascinating city! Some down time included a boat architecture tour and some great jazz at a bar in place from the 30’s whose patrons included Al Capone (the Saskatchewan connection). I will be going back.

The conference had some great keynote speakers including Alan Alda who spoke on communicating science and medicine, and emphasized the importance of empathy and clarity in communicating both.

Some of the challenges we have had provincially to get a Strategy for Patient Oriented Research initiative into CIHR relate to our challenges in communicating what science can do for our provincial healthcare system. Something else we all must work on, I believe.

Another keynote speaker was Mahzarin R. Banaji, one of the authors of Blindspot: Hidden Biases of Good People. She is a spellbinding speaker with an important message based on rigorous neuroscience and cognitive psychology research. This reminds me of the work on cognitive and affective bias in diagnostic reasoning and the work we did at Dalhousie with Dr. Pat Croskerry. I am interested in hearing from faculty members who have an interest in this topic.

However, it was the workshop on Longitudinal Integrated Clerkships (LIC) that I think was a historic moment for the AAMC. I am sure many are familiar with LIC’s but for those who are not it is an entirely different model for teaching clinical medicine and for structuring third year.

While Australian’s and Canadian’s (UBC, U of A, U of C, NOSM and Dalhousie) are noted leaders in this model, it has been spreading rapidly throughout the world in the last 10 years. A number of new medical schools have gone with the LIC model as their sole method of teaching third year (e.g. NOSM).

The LIC has its curriculum organized on a longitudinal and integrated basis. It is distinguished by the absence of traditional discipline-based rotations. Models vary, but students are often based in a family practice for two  or three half-days per week and have additional clinical experiences with other disciplines and in hospitals scheduled through the rest of the week.

Students are encouraged to follow their own bank of patients over time, and benefit from the continuity of supervision as preceptors see their clinical skills develop over the entire year.

Models are often based in rural communities, but urban models are also successful (Harvard, UCSF). The salient features have been summarized as continuity of patient care, curriculum, supervision and empathy!

I have attended meetings of the Consortium of LIC’s (CLIC) since 2008.  There is no doubt there is a counter-culture aspect to this group who truly believe they are going to profoundly change clinical education. And to their credit, they have been meticulous in doing the medical education research to prove their point. Repeatedly evidence has been documented that LIC students do as well or better on objective standardized testing (and some evidence for better long-term retention).

Furthermore, these learners have better clinical skills and greater preservation of the empathy they had when they entered medical school. Anecdotally it is noted that many program directors search out LIC candidates at CaRMS time. And for our communities and our funders, there is lots of evidence LIC students choose more generalist careers and rural practice settings.


This workshop was remarkable in that AAMC and LCME (the American accrediting body) would not often be described as counter-culture. All of the above was presented together by faculty members from such disparate place as Harvard University and the University of South Dakota and summed up by Dr. Dan Hunt, a noted accreditor for the LCME and medical educator.

Dr. Hunt helped with the launch of the Northern Ontario School of Medicine where all the students do an eight-month LIC in third year.  With a red hat on, representing LCME, Dr. Hunt stated LCME “does not care” what model of clerkship a medical school uses. With a blue hat, on representing himself, Dr. Hunt wholeheartedly endorsed the LIC as an excellent and possibly better way of teaching third year.

The traditional rotation-based clerkship was certainly perfectly designed for John Hopkins Hospital in 1910 and obviously has continued to serve us well as evidenced by the personal experience of many of us. However, I do believe we are approaching a “the world is not flat moment” around the best approaches to clinical teaching in UGME.

Last year we had a pilot of an LIC in Prince Albert and we have decided to take some time this upcoming year to refine that model. We will look to our strategic plan for distributed medical education to identify where we should establish LIC’s in Saskatchewan.

I invite faculty members and students to apprize themselves of the literature on LIC’s and enter into a discussion about the role of LIC’s here in our CoM.

Choosing Wisely Canada; Appropriateness

Are you familiar with these phrases? These are part of an international movement that I believe has the greatest potential to make our health system sustainable.

All clinicians are aware of the waste in our system and examples are plentiful.  Consider the back x-ray done for acute back pain after a weekend of yard work.

Evidence abounds that without any red flags in the clinical presentation, this x-ray is simply waste.  Often, the busy doctor knows it is waste, but does not have the time, evidence, and alternate resources for the patient, or possibly the negotiating skills to explain why the test is unnecessary.

But waste it is!

We can all find many more examples. Why is there remarkable variation in the rates for some major surgical procedures between Regina and Saskatoon?  Why is there duplication of tests by FD’s and consultants? Why are high-cost statins prescribed? How do people get antibiotics for a two-day illness consisting of a sore throat accompanied by a runny nose? Lots of evidence suggests 20% of what we do brings no benefit to our patients.

Now I know there always exceptions to these examples, but that’s why we call it clinical judgment. While making our system more efficient is essential, continuing to do wrong or unnecessary interventions more efficiently will still be waste.

The greatest potential for improving our system is changing clinical practice and models of care.  And physicians worldwide are leading this initiative.

The American Board of Internal Medicine (ABIM) launched Choosing Wisely in 2012 in the US. This led eventually to the ABIM calling on all specialty organizations to list their top 5 “Things Providers and Patients Should Question”.

So for the American Academy of Family Physicians, the back pain above is the first example. In fact, ABIM goes a step further.  In their charter, Medical professionalism in the new millennium: a Physician Charter, they state physicians have a responsibility to promote health equity when resources are scarce. When Dr. Chris Simpson, President of CMA, spoke earlier in November about the “civic professionalism” of our students, this is part of what he was talking about.

“Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care.”

It is led by Dr. Wendy Levinson, an internist at U of T, for the CMA and supported by the SMA. “As physicians we are stewards of our patients’ health and it is our responsibility to partner with them in making appropriate choices for their care,” says Dr. Slavik, SMA President, “Doing so will not only ensure that our patients receive optimal care, but will also ensure that we have a sustainable healthcare system.”

Earlier this month,  the Academy of Medical Royal Colleges in the UK released a report:Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care”. One of the intriguing aspects of this report is how the potential savings of various interventions are listed in terms of both financial cost and carbon cost. It is quite sobering to see what we could do for our planet by choosing wisely! They also state “that doctors have an ethical duty not to waste.”

Appropriateness is another common term used for the same philosophy.  Recently the province issued a call for a Physician Co-Lead, Clinical Appropriateness of Care Program. This will be a major initiative by the Ministry of Health.

And this is a major opportunity for the College of Medicine.  What can be our role?

I see three: teaching these skills to the next generation; CME for current practitioners; and doing the research on clinical practice in our province that leads to everyone “choosing wisely”.

I had the opportunity 18 months ago to participate in a conference at Harvard on how we teach the knowledge and skills to support wise stewardship of health care resources. While we have been great at teaching patient-centered communication in the last 20 years, we do not teach the negotiating skills that allow practitioners and patients to easily deal with these issues. We must provide this content to our learners and model the corresponding care.  Through CME, we must do the same for our practitioners.

The Canadian Institute for Health Research has a funding stream called the Strategy for Patient Oriented Research (SPOR) to support real-time research on clinical practice here in Saskatchewan. It is imperative our College of Medicine takes a leadership role in this important initiative and do the research on our practice here in Saskatchewan that will lead to better care and ideally to zero waste.

Please take the time to visit these websites, learn more about Choosing Wisely Canada, discuss with colleagues and friends, and tell me how we should lead at the College of Medicine.


I had the privilege to do the introduction and welcome at this week’s Health Innovation and Public Policy Conference.  I joked that I loved the words, “student-led” because I was confidant it would be high-quality with little work on the college’s part! Well, I had no idea how right I was.

This got me reflecting on the huge contribution our students make to the College of Medicine and the magnitude of the student-led activities here at the U of S. First let me comment on the conference and then come back to our students.

This was the second annual Health Innovation and Public Policy Conference and my only regret is that I missed last year’s conference. This is entirely a student-led initiative. As I noted that day, Honorable Rona Ambrose, Canada’s  Minister of Health, has created an Advisory Panel on Healthcare Innovation.  Just these past two weeks, I have worked with my fellow Deans at the AFMC to prepare a brief for that panel. I think we could have asked the U of S students to do it for us.

The quality of the speakers at the HIPPI Conference was remarkable. Dr. Chris Simpson (another Maritimer and graduate of my alma mater) who is President of the CMA, spoke of the need for transformational change that moved the system from being all about doctors and hospitals to one that was truly patient-centered and sustainable. I believe our CMA has become a national leader in calling for system change focused on the patient.

Dr. Karima Velj, President of the Canadian Nurses Association, had very complimentary messages and spoke of inter-professional care and expanded roles for healthcare providers.

Dr. Gary Bloch, a family doctor with an inner-city practice in Toronto, spoke eloquently about the need for doctors to go beyond taking a socio-economic history and treat poverty like it is a disease.

And to cap the event off, we had excellent speakers from the U of S with Dr. Veronica McKinney providing a vivid description of the healthcare challenges in our North and the good work of Northern Medical Services.  Dr. Ivar Mendez described meeting some of those challenges in our North with remote presence technology.  It was a remarkable afternoon capped off with an excellent panel discussion.

Back to our students.

All medical schools have bright students and great student leaders.  However, I think the initiative shown by our students here at U of S is more than above average!

I attended the One Health Leadership Experience late in August, which is a conference for students from all of health sciences colleges on campus.  This is sponsored by the Veterinary College and the Council of Health Science Deans and led by WCVM Dean, Dr. Doug Freeman. The speakers were amazing but the turnout and enthusiastic participation of students on the last free weekend of their summer was quite overwhelming.

In early September, the Student Medical Society organized the 11th Annual Miles for Smiles.  This fun walk/run event took place in both Saskatoon and Regina, with all proceeds going to support the Children’s Hospital Foundation of Saskatchewan.  Although I was unable to attend personally, I understand the cool, rainy weather did nothing to dampen spirits or speeds!

On September 18, student volunteers from our School of Physical Therapy participated in Shinerama, the largest post-secondary fundraiser in Canada, which raises money for Cystic Fibrosis research and treatment. Our School has been involved in Shinerama since 1966. The students involved in Shine Day went out in the streets of Saskatoon and on the U of S campus bringing in donations by shining shoes, singing songs, dancing, and doing whatever they could to raise money for CF research and treatment.  As a profession that helps treat symptoms in Cystic Fibrosis patients, it has always been an important fundraiser. This year our campaign raised $29,474.54 for Cystic Fibrosis research!

I attended part of the Hacking Health Saskatoon weekend late in September.  In their words: “Hacking Health is designed to improve healthcare by inviting technology creators and healthcare professionals to collaborate on realistic, human-centric solutions to front-line problems. Our hackathons are fun, intense, hands-on events where small teams tackle tough problems in a supportive community of peers and mentors.”

Medical and other health professional students worked all weekend with computer science, business and engineering students to create technical solutions to health care problems.  Hacking Health is a national and international movement and at the conference this week one of its students leaders lobbied and convinced Dr. Simpson that the CMA should become a sponsor. It was health innovation advocacy in action and a beautiful thing to watch!!

Back in October, I was also privileged to attend another entirely student-led event, the Global Health Conference.  It was the third annual gathering and this year was focused on immigrant and refugee health.  Saskatchewan has a growing number of newcomer families, and health is a key factor in successfully settling and integrating people into our communities.  Speakers discussed language and cultural barriers in our health care system and challenges related to lack of resources, coordination and cross-culturally trained health care workers.  The event was a prime example of inter-disciplinary work and social accountability.

Of course SWITCH, is a long standing student-led initiative supported by faculty members that provides both learning and care by students from all health professions at the Westside Community Clinic.  “SWITCH was created by students in order to enrich educational experiences and to provide much needed services for Saskatoon’s core neighborhoods.”  Please visit  to learn more. Our College has a national reputation as a leader in Social Accountability and our students play a big role in that reputation.

In summary we have an amazingly active student body who are doing great work that matters.  Dr. Chis Simpson commented on the “civic professionalism” of our students and the hope that he has for the future of our healthcare system because of the energy, values and advocacy that the students of today will bring to the workplace.

I believe he is right.