AN

internist's perspective

Dr. ANGELA CHEUNG

Dr. Angela Cheung is a senior clinician scientist at the Toronto General Research Institute (TGRI), investigating osteoporosis and post-menopausal health problems, as well as a professor of Medicine at the University of Toronto and a practising general internist.

THE    DAUGHTER   OP   A   HONG   KONG   PEDIATRICIAN,   Angela Cheung's introduction to medicine was made for her even before her teens. Helping out in her father's office, she found herself calling parents to give them advice on how to treat their sick children.

She did an undergraduate degree in physics at Bryn Mawr College and her medical degree at Johns Hopkins University. By then, her family had relocated from Hong Kong to Toronto, a fortuitous development that, later, allowed her to immigrate to Canada as a physician under family reunification policies.

At Johns Hopkins, Cheung debated between choosing internal medicine or pediatrics, but ultimately decided her "personality was not cut out for family medicine. I want depth. I need to know more. I enjoyed internal medicine more than pediatrics. It was easier and more satisfying to deal with adults."

In Toronto, Cheung did a three-year residency, then a fourth year in general internal medicine — at the time, one of only three such residents in all of Toronto. Again, she wrestled with the next decision — this time between the conflicting tugs of clinical practice and research. "I didn't want to give up on either. It was the bane of my work life. I had to choose, but was on the fence. So I went away to Harvard to do a four-year Ph.D., with a thesis on post-menopausal health."

She returned to Toronto four years later as junior staff, one of only two women practising general internal medicine. There are still few women in the field. Cheung says she is the first woman to attain a professorship while climbing through the ranks as an academic general internist.   

"It was a stressful period. I had just had a baby and, at the time, you were expected to effectively earn your salary by writing and winning research grant proposals."

Cheung had been exposed to Dr. Herbert Ho Ping Kong as a medical resident and had admired his humane and caring approach — not only to patients but to his team of doctors. "He does have a human touch and he does care how his mentees are doing. I remember when I was on junior staff at the Toronto General and he was at the Western, he made a special trip here to see how I was doing. That made an impression on me. He wanted to assure me that things would be okay. It did help lift my spirits. He's been a mentor to me. If he sees something, he points the way." The problem, she says, is that there are very few clinicians of HPK's calibre.

Coming to Canada from the United States, Cheung says she noticed that she was more proficient in doing medical procedures, such as taps and punctures. "So I was fairly efficient in looking after patients." But she was less skilled, she found, in being able to distinguish between types of heart murmurs. "When I came as a first-year resident, there were various murmurs I had never even heard." Now, when she teaches her own students, she not only uses Harvey — the University Health Network's murmur simulator — but also takes them to patient bedsides to hear the real thing, "because there is variation. Everyone is different."

Cheung takes a measured approach to the rise of technology in medicine. "It can put a distance between patient and doctor," she says. "But it can also make things easier and improve things. You can use technology to help care for the patient, but you can also miss the point, by concentrating on the technology and not the patient. Then it becomes a problem."

Although the proliferation of medical knowledge has spurred specialization and sub-specialization, Cheung is optimistic that internal medicine — the role of the academic generalist — will not soon fade away. If anything, it will become more important.

But other changes are likely. Cheung sits on an international committee now examining the future of health policy. Some procedures, she concedes — laser eye surgery, for example — simply don't require the level of education now demanded. "Do we really need someone to have gone through four years of medical school, four years of residency and another three years of specialization to carry out a relatively simple procedure that a high-school student with good hand-eye coordination could perform?" she asks. "Do we really need that kind of vigorous training, which requires people to rack up huge debts and then charge a thousand dollars to help pay off the debt?"

Similarly, she asks, if you go for a colonoscopy, you obviously want it done by an experienced specialist for whom the procedure is routine, someone who will know what to look for. But do we need someone who has 12 to 15 years of training to do a colonoscopy? "Health care costs are becoming a larger portion of the GDP and can, we afford it?" Medicine needs to be rational, she maintains. "Why should someone who intends to do laser eye surgery have to do a rotation in orthopedic surgery? You learn a lot of things in medical school that you don't actually retain."

What medical schools need to do a better of job of teaching, she says, are the soft skills. "Yes, you need to know how to put in a line, because if you do it wrong, you puncture a lung. But you also need to know how to break bad news, how to sit with patients and discuss a mistake that might have been made, how to listen, how to be a comfort. It's TLC. Sometimes, I tell my students, 'You have to just let the patient speak or vent. Don't sit at the nurse's station and just concentrate on the numbers from their tests and forget about the patient.' That's really crucial. Our job is to look after patients, not numbers."

CARDIOLOGISTS PERSPECTIVE

Dr. MATTHEW SIBBALD

Dr. Matthew Sibbald is an award-winning clinical teacher at the University of Toronto and an interventional cardiologist at Toronto's University Health Network. He did his residency at the University of Toronto, was named chief resident and later completed both his M.A. and Ph.D. in medical education at the University of Maastricht in the Netherlands.

Like many of the emerging medical superstars now gathered around Toronto Western Hospital's Centre for Excellence in Education and Practice (CEEP), Dr. Matthew Sibbald had his first introduction to Dr. Herbert Ho Ping Kong in medical school.

The way it typically works, Sibbald explains, is that students spend the first two years in the classroom and then, during the next two years, graduate to clerkships, shadowing residents and interns. "It's an eye-opening time," he says, "because you are really seeing patients and the inside of hospital for the first time. It can be overwhelming."

His introduction was Morning Report, a Socratic teaching session attended by doctors, interns, residents and clerks. "Herbert often led it, and you discuss a patient's case. But he would lead you to the diagnosis by means of these very strange verbal clues. What the heck is going on? I was totally mystified."

Among students, there was a culture of trying to prepare for these morning sessions, by sharing often-used clues on the shuttle bus between hospitals. "'Howling at the moon' was used to incite a diagnosis of lupus," Sibbald remembers. "I think what he was trying to do was to get people primed and ready to jump to these subtleties, so that these things would come to mind when faced with difficult cases."

Later, Sibbald followed Ho Ping Kong as he treated patients in a clinic setting. "He often found some very unusual things. I remember one gentleman who had been unwell for months, losing weight and sweating and feeling deeply fatigued. He'd been sent from his GP to an internist, who had done an elaborate series of tests, which proved inconclusive.

"HPK found a prominent heart murmur," Sibbald recalls, "which led to some blood cultures and, ultimately, a diagnosis of endocarditis on his aortic valve. He had surgery in rather short order. In clinic, there were multiple signs that this diagnosis was in play, but they were all individually subtle and easily passed over. The murmur was the sentinel piece and, at that point in my training, I don't think I fully appreciated the severity of the diagnosis or the difficulty in making it."

The subtleties included finding a slightly enlarged spleen, "not something everyone would routinely look for or, if they did, focussing on that abnormality and connecting it to other things," Sibbald says. "Another one was tiny hemorrhages under the nail beds — so-called splinter hemorrhages in the hands and/or feet. That, again, might not be noticed or, if noticed, not considered germane. But in the cluster of a very sick person and an enlarged spleen, it is something to consider."

Another distinguishing feature of these clinics was the extraordinary range of rare and difficult cases that Ho Ping Kong was called on to diagnose. In most clinics, clerks were exposed to generalized, not very serious problems for which the solution was relatively predictable. "Even at the specialist level," Sibbald says, "much of medicine is about reassurance and basic testing around common diseases. Those rules did not apply in his clinics. It was always fascinating."

Ho Ping Kong was particularly strong, he says, with finding variations on vasculitis, which is an inflammation of the blood vessels that can present in many different and unusual ways. "A disease that is at once rare and presents in unusual ways can be very difficult to diagnose. Much depends on the size of the blood vessels afflicted and the patterns. When the medium-sized vessels are inflamed, people get very sick, with accompanying weight loss. But there is no blood work you can do to verify it. Even a blood indicia of inflammation, like a sedimentation rate, doesn't give you the diagnosis. You need an experienced clinician who has seen it before. Or you need specialized imaging which, when I was resident, was not routinely available. I learned a lot from him about these illnesses. I remember a case arriving by ambulance from another hospital, where they could not make the diagnosis ... He took one look at the patient and said, 'I know what this — it's polyarteritis. You need prednisone.' And the residents would just look at each other with astonishment. How is it possible to walk into a room and see someone for the first time and in three minutes make the diagnosis with so little other corroborating data? And the answer is pattern recognition —he's seen it before and he remembers what to look for."

After his clinics, Sibbald recalls running home to his textbooks to find more information on exotic diseases and medical terms he heard Ho Pong Kong routinely discuss. Only with time and more exposure did "I grasp how warm and disarming he can be," says Sibbald. "He sees the whole person, not just a patient. They become really attached to him and the attraction is personal."

The challenge faced by medical schools trying to model that kind of humane practice is enormous, he allows. "I do think it's a teachable entity, although few trainees," Sibbald observes, "express much interest in learning how to engage patients or navigate a system. They want to learn about specific diseases or a group of diseases. But the other has to be role modelled for them, perhaps by taking trainees aside after they've examined a patient and asking, 'Why do you think that didn't go as well as it might have?'"

"Learning medicine is like putting up a scaffold to organize what is just a sea of information," he says. "A lot of it is very structured and hard to apply. Herbert's way of teaching is very different. It comes from his experience and is very much centred on the art, trying to connect the dots, and it's practically helpful."

The diagnostic charts taught in lectures or in textbooks tend to be clustered around pathologic entities — a group of diseases that all connect pathologically, Sibbald explains. "You can have all that information in your head, but when you walk into a room with a patient, it doesn't necessarily come out. So what HPK does is reorganize that information for trainees, to make it useful in real-life terms."

One of Sibbald's own research interests is in documenting how doctors reorganize knowledge, making the transition from book learning to practical learning, and showing how experts do it. "I think what makes an expert is not the facts that they know, but how they organize them, both with patients and with medical information. And facts change. You have to build your own functional knowledge base. But like most skills, it needs to be practised. Less time in the classroom, perhaps, and more with patients, particularly because most medical students will already have spent three or four years in lecture theatres acquiring scholarly, scientific knowledge in biology, chemistry and anatomy and physics. What's learned in the classroom can be applied well in the classroom, but poorly outside of it. When you have to struggle with a clinical problem, trying to determine what information is valuable, that's a much more useful task than having a lecturer tell you how the world is organized."

The emphasis laid on the sciences as prerequisites for medicine, Sibbald argues, may tailor the dominant character that emerges. To advance the art of medical practice, he suggests, more emphasis likely needs to be put on teaching the humanities — history, philosophy and the softer social sciences. "These are intellectually expanding domains for people on their own professional journey and helpful ways of looking at the world and life. By exposing students to other streams of knowledge, they may begin to see the possibilities of learning in other places. It's not a major focus in Canadian medical schools."

Sibbald credits Ho Ping Kong with being both an advocate and a mentor for his research interests. "He encouraged me. He told me what I needed to do if I wanted to go the route I have. He found me a way to fund it and organize it, while sheltering me from political forces within the institution, and still allowing me to be connected to patients and to the clinic."

In 2011, Sibbald earned a master's degree in Health Professions Education from the University of Maastricht in the Netherlands, and in 2013 completed his Ph.D. there as well. His thesis was entitled Is that Tour Final Answer? How Doctors Should Check Decisions. "I think psychology has something to say about how we make decisions and when we need to pause," he says. "We all live with uncertainty, but we can't be incapacitated by it. We still have to act and we learn a lot from our mistakes. Having a culture in which we can talk about them is healthy."

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