Med Ed Manifesto

1       Introduction

The high standard of excellence in medical education today must not be taken for granted. In the early twentieth century, medical education in North America was in a deplorable condition. It was for this reason that the Council on Medical Education (CME) was formed in 1904 by the American Medical Association (AMA) with the primary purpose of reforming the ailing system. Around the same time, The Carnegie Foundation determined to focus its philanthropic attention on the improvement of healthcare in America. In 1908, the AMA CME commissioned The Carnegie Foundation to conduct a survey of medical education in America and Canada in an effort to advance the reform agenda. The person selected to conduct the survey was Abraham Flexner. Flexner was not a physician nor scientist. Flexner was an educator. A former high school teacher, Flexner went on to obtain his MPhil at Harvard and traveled extensively in Europe studying pedagogical methods used at universities there. It was the publication of his exhortation for the American education system in his book, The American College, that brought Flexner’s name to the attention of the then Head of The Carnegie Foundation, Harry Pritchett, who subsequently appointed Flexner to conduct the survey. In his 1910 report, Medical Education in the United States and Canada, Flexner articulated basic recommendations that soon formed the blueprint of American and Canadian medical education, which some have attributed as the catalyst for the most profound reformation of medical education and practice in history – not to mention generous financial gifts from the Rockefeller and Carnegie foundations. Over 100 years later, the core principles by which most medical schools operate by today can find their origin in Flexner’s 1910 report.(1)

Flexner’s report was not perfect – in fact, it was far from it. Besides violating the rights of women and people of color, it majored on scientific knowledge as a prelude for clinical training with such blind passion that it ultimately overlooked two imperatives of the profession: medical ethos and social responsibility. Flexner borrowed this mentality from the German medical education model.(1) “An education in medicine,” wrote Flexner, “involves both learning and learning how; the student cannot effectively know, unless he knows how.” Patients became first and foremost as serving the academic pursuits of the medical professor, and involvement in the arts and humanities of medicine was unimportant for the physician envisioned by Flexner.(1) From this originated the widespread adoption of traditional “2+2” curricular structure consisting of two years instruction in basic sciences (e.g., anatomy, physiology) followed by two years of clinical training in a teaching hospital.(2)(3) In addition, science was to be the animating force in the physician’s life, and the advancement of scientific knowledge was to trump all other commitments of the academic physician. Flexner, an educator whose philosophy was shaped by a pathologist (William Henry Welch) and their shared appreciation for German tradition, can hardly bear all the blame for his apparent oversight of the service and healing role of the physician.(1)

One of the earliest critics of the movement spurred by Flexner’s report was a contemporary of Flexner himself, Dr. William Osler. While Osler paid respect to the central focus of science in medicine, he did so only as this focus served the more important priorities of patient welfare and education of students. Therefore, Osler firmly believed that the Flexnerians had their priorities wrong; however, upon relocating from America to England to assume the Regius Professorship at Oxford, Osler’s voice in the controversy went near silent. As for Osler’s followers who remained in America, their objections were drowned out by the deluge of conflict of interest linked to the implementation of the “full-time” system that provided an adequate salary (made possible by extravagant donations from the aforementioned foundations) enabling medical professors to be freed from any patient care responsibilities and dedicate their lives to research and teaching.(1)

Since Flexner’s report, virtually every aspect of medicine has been shaken by tectonic changes – our understanding of human learning has exploded, novel technologies and medications have revolutionized diagnosis and treatment, the profession expanded its role at the micro-, meso-, and macro-levels while simultaneously specializing and sub-specializing its scope of practice, and the healthcare system has become increasingly complex in terms of delivery, financing, and public policy.(4) Essentially, medicine has come full circle, and nearly every organization within the medical profession – faculties, universities, hospitals, licensing authorities, accreditation bodies, specialty boards, and medical associations – is re-examining the foundation: medical education. Once again, in 2010, The Carnegie Foundation commissioned a team to examine medical education across the USA and make recommendations for the future, which culminated in the book, Educating Physicians: A Call for Reform of Medical School and Residency.(5) The team identified several important gaps where medical education is failing to meet current and future demands. Particular to this study, the team found that medical education is not learner centered, makes poor connections between formal knowledge and experiential learning, and does not make adequate use of the learning sciences. Further, the team found the “2+2” system to be an inadequate approach for today, which is corroborated elsewhere,(6)(7) and called for integration of knowledge and skills in the basic, clinical, and social sciences with clinical experiences both at the medical student and resident level.(4) As such, integration is a strategic priority for the future of medical education.(8)

1.1       Integrated curriculum

The integrated curriculum has been defined as “a fully synchronous, trans-disciplinary delivery of information between the foundational sciences and the applied sciences throughout all years of a medical school curriculum.”(9) The etymology of the term integrate has its root in the Latin, integrat, meaning ‘made whole’ and is closely related to the English term, integer, meaning ‘whole’. More than being ‘made whole’, the modern definition of integration in medical education portrays the thought of making whole by breaking down barriers that traditionally divided the foundational and applied sciences and believes that connections thus made between these subjects will be improved and will enhance learners’ retention of knowledge and development of clinical skills.(9)

The integrated curriculum was first reviewed in general education by Beane in 1977(10) and was later described within the context of medical education by Harden et al. in 1984.(11) The “McMaster approach” to medical education is one of the earliest examples of its implementation, development, and revision.(12) Many learning theories have been explored to understand how adults learn and how integration enhances learning in the context of medical education.(13) Several models and levels (program-, course-, and session-level) of integration have also been described and reviewed.(14) At the program level, integration has been described as horizontal integration (across disciplines but within a finite period of time, e.g., combining courses that were once separate into a year-long introductory course),(15) vertical integration (across time, e.g., the “Z-shaped model” of progressive introduction to clinical practice while maintaining a persistent basic science component throughout all years of the curriculum),(16) or spiral integration (combination of both horizontal and vertical, i.e., learning both basic and clinical sciences across time and subject matter).(17) Course-level integration refers to the contextualization of basic science concept teaching (e.g., Poiseuille’s law and blood flow within a vessel)(18,19) and shared teaching (e.g., basic scientists and clinicians teaching a course together).(20) Session-level integration are those micro-level activities used day to day to teach content and include specific learning interventions such as the causal network where pathologies are taught from a cause-effect perspective and etiology is linked to pathophysiology and clinical presentation.(21–24)

Integration activities are often undertaken with the expectation that organizational change will achieve integration. However, it is clear that adopting an integrated curriculum in a medical school will not automatically produce cognitive integration within the minds of its learners.(14) Of note, Kulasegaram et al. (2013) point out that integration of basic science and clinical practice is likely most effectively achieved at the level where students make direct contact with the content of the formal curriculum, that is, the session level. Whereas integration is usually described as methods and techniques, it is better framed as the action of learning. Thus, our understanding of integration in medical education should emphasize the cognitive activity that takes place within the learner as he or she links clinical concepts with basic science.(14)

1.2       Cognitive integration

Cognitive integration occurs when a conceptual cognitive connection is made between different knowledge sources,(25)(26) but it is more than that. The learner-centered definition of integration in the medical education curriculum refers to the process in which links and interrelations are formed between different types of knowledge (e.g., basic science, clinical science) within the learner in a manner that enhances understanding and performance of clinical activities (e.g., diagnosis, management).(27) Therefore, the scope of cognitive integration extends beyond acquisition, interrelation, and retention of different types of knowledge to the transfer and application of this knowledge to different situations. Teaching basic and clinical sciences in an integrated fashion to novice learners seems to support an organized cognitive conceptual coherence with the learner that has been shown to result in superior knowledge retention and application to solve diagnostic problems when compared with teaching basic and clinical sciences separately.(21–25,28–31)

The end goal of integrated curricular reform is, therefore, not merely the performance of integration activities such as organizing delivery of content in an integrated manner. Rather, the end goal is a cognitive action within the student that enhances acquisition, interrelation, and retention of basic and clinical science knowledge that is borne out in the performance of clinical skills. An objective end goal lends clarity to how evaluating the effectiveness of integration efforts might be achieved. A given integration strategy could be evaluated by assessing how students utilize basic science knowledge in the performance of a specific clinical skill.(14)

Cognitive integration is preceded by knowledge, which is preceded by memory, which is preceded by learning; therefore, a brief review of learning and memory is incumbent. In their book, Make it Stick, authors and cognitive psychologists Peter Brown, Henry Roediger, and Mark McDaniel define learning as acquiring knowledge and skills and having them readily available from memory so one can makes sense of future problems and opportunities. They emphasize three immutable aspects of learning, namely, learning requires memory, individuals need to keep learning and remembering for their entire lives, and learning is an acquired skill (and the most effective strategies are often counterintuitive).(32) Since the late 19th century, the cognitive psychology and education literature has consistently and voluminously yielded credence to two critical components for learning and memory: retrieval practice and distributed practice.(33–35)

1.3       Retrieval practice

Retrieval practice refers to the exercise of actively recalling a previously learned fact. Two key findings central to the discussion of retrieval practice are the testing effect and the retrieval-effort effect.

The testing effect refers to the finding that actively recalling a previously learned fact (re-testing, repeated testing) leads to increased long-term retention of that fact than if it were passively read (re-studying, repeated studying).(36–39) In education, testing is most frequently utilized as a tool to evaluate what the student knows; however, empirical research supports that re-testing substantially enhances retention when compared with re-studying(37,40,41) and potentiates the future learning of new materials.(42) One explanation for the testing effect is the elaborative retrieval hypothesis, which posits that the retrieval process during testing activates elaborative information related to the item being recalled thereby facilitating successful recall of the item in subsequent recall attempts via reactivation of any of this related information.(43,44) As such, testing is a powerful tool not only for assessing learning but also for improving it.(36,45) The act of recalling a memory changes the memory itself by interrupting forgetting and making it easier to recall again later.(32) Attempting to retrieve a memory, even if unsuccessful, appears to enhance encoding for recall in a subsequent retrieval period.(46) Beyond the benefits of long-term retention, the testing effect induces flexibility in recalled knowledge enabling it to be transferred and applied to novel situations. Testing assists the learner in organizing knowledge, forming a coherent knowledge base, and recalling related information.(37,47) The benefits of the testing effect are conveyed by one of the terms often used to describing the concept, “test-enhanced learning”.(36)

The retrieval-effort effect refers to the observation that a memory that is more difficult to recall during retrieval practice is more likely to be retained better in the long-term.(43,44,48) In other words, difficult initial retrieval facilitates subsequent recall,(49) and effortful learning produces durable learning.(50) It is evident that when recall is required after a meaningful amount of time has elapsed and some forgetting has occurred, the retrieval is more difficult and feels less productive; however, the increased effort for retrieval produces a more durable memory by strengthening the retrieval route and enabling more versatile transfer and application in future novel situations.(32) The effect of taking the stairs rather than the elevator on development of strength, balance, coordination, agility, and stamina is a helpful parallel.

1.4       Distributed practice

Distributed practice refers to the exercise of separating review episodes (whether actively recalling or passively reading) for a given item by a measurable time lag.(51) Central to the discussion of distributed practice is the spacing effect.

The spacing effect refers to the finding that the time interval separating different retrieval attempts of the same fact impacts upon acquisition and retention of the fact in subsequent retrieval attempts.(51) If retrieval practice was performed by testing and retesting the learner again and again without permitting any interval forgetting, it would become mindless repetition, and the benefit of the retrieval-effort effect would be lost.(32) Indeed, the evidences supports that when the retrieval practice takes place is as important as the act of retrieval practice itself, and this evidence dates back as far as 1885 to the pioneering work of Hermann Ebbinghaus on the topic of temporal distribution of practice.(51) The spacing effect is thus intimately related to the retrieval-effort effect – after an initial test, spacing out retrieval attempts permits more forgetting, which makes subsequent retrieval more effortful and retention more durable. Research is clear that the timing of retrieval attempts or, in other words,  the space of time elapsed between attempts, affects retention. For any given subsequent test, there exists a spacing interval between previous retrieval tests at which retention will be optimized.(51,52) In general, the optimal spacing interval increases as the duration over which the information needs to be retained increases.(51) When retrieval practice attempts for a fact occurs more than twice, there is inherently more than one spacing interval, and in comparison to the first spacing interval, the subsequent spacing intervals may be equal (fixed), progressively longer (expanding), or progressively shorter (contracting). The evidence suggests that expanding spacing intervals either benefit learning(51) or produce effects similar to retrieval practice with fixed spacing.(51,53)

The corollary to an optimum spacing interval is that too short or too long a space between retrieval attempts can reduce retrieval success at a subsequent test,(54) which may explain some conflicting results in the literature on distributed practice.(55) Indeed, when the spacing interval is too short or the learner is not subjected to any interruptions of intervening items or time, the learning is said to be massed in contrast to spaced.(51) Note that massed practice is to massed learning as distributed practice is to spaced learning, and cramming is a form of massed practice. Hundreds of empirical studies and several large systematic reviews and metanalyses have confirmed that distributed practice increases retention (51,56–59) and that the benefits of distributed practice far outweigh the benefits of massed practice.(51,58,59) Several theories attempt to explain how distributed practice accomplishes such results;(60,61) however, no single theory can account for all the effects observed empirically, so distributed practice remains a topic of active research.(51) A neurobiological basis for the superiority of the spacing effect over massed learning has been described through synaptic mechanisms.(62)

Distributed practice has been shown to confer learning benefits, particularly better retention, over massed practice in medical residents.(63–65) Incorporation of distributed practice into the traditional face-to-face lecture format increases time spent self-studying and learners’ satisfaction compared to the traditional format alone in dental students.(66) Distributed practice accelerates learning of surgical skills and protects against performance drop over time when compared with massed practice in medical students.(67) Distributed practice seems to confer benefits across a wide range of ages and has practical implications in that teaching content delivered according to a distributed presentation schedule has learning benefits over a massed or clustered presentation schedule.(68)

In today’s world, where sleep deprivation among students is nearly universal, a further benefit of distributed practice is that, due to the spacing effect, it appears to confer strong protection against the effects of sleep restriction on recall performance when compared to massed practice (i.e., cramming), which often goes hand-in-hand with sleep restriction.(69)

1.5       Learning and memory in the real world

Given what modern cognitive psychology research has discovered about the best methods of learning and memory retention, namely, that retrieval and distributed practice have powerful effects to this regard across an impressive range of practice-test formats, kinds of material, learner ages, outcome measures, and retention intervals,(35) how are these methods viewed and utilized today? Unfortunately, learning how to learn is not a standard component of most educational curricula, including medical school.(33,70)

Cramming is the most commonly employed method of studying – likely because it seems to be the easiest and fastest way to learn. Cramming is the path of least resistance for the learner; however, cramming is not effortful learning and, therefore, not durable. Approximately 75% of content learned by cramming is lost within 48 hours.(32,71) Further, cramming is likely to deceive the learner – rereading material over and over again with a short or no spacing interval in between presentations results in increased familiarity with the content, which can easily be mistaken as mastery.(32,72)

It is counterintuitive that the process of effortful retrieval at spaced intervals, allowing some forgetting to occur, improves learning and strengthens memory. Indeed, decades of research has repeatedly confirmed that the majority of teachers and learners do not appreciate that conditions which promise rapid acquisition often to not promote long-term retention nor do they understand what strategies are most effective for retention.(36,39,72–75) Retrieval and distributed practice are less commonly employed as pedagogical strategies by teachers and as self-regulatory strategies by learners,(41) whereas cramming and massing in the form of rereading is used by the majority of learners in preparation for summative testing.(35,72) Even when students achieve better test scores with retrieval practice then they have with cramming, they still believe that cramming is more effective.(36,76) According to Tullis et al.,(77) all previous laboratory experiments investigating learners’ metacognitive monitoring of their learning strategy effectiveness, participants judged massed practiced items as more likely to be remembered but actually remembered more of the retrieval practiced items. Learners lack cognitive awareness of the mnemonic benefits of retrieval(39,78) and distributed practice.(79)

Instead of using practice testing to improve their memory, students self-test to diagnose what they do and do not remember in order to guide further study, often without realizing that doing so improves their memory.(75) This usage of self-testing solely as a diagnostic tool indicates that most students who use self-testing only recognize its indirect benefits.(75,80) In a recent study, the authors contend that learners’ metacognitive knowledge of the benefits of retrieval practice may be more complex than simple unawareness and that their study method decisions may be risk averse, choosing to take practice tests only when their confidence in successful retrieval is unnecessarily high.(81)

Another explanation is that there is a disconnect between the real-world and the laboratory given that students under experimental settings may be less motivated to retain information than they would be in classroom settings and, therefore, may recognize more benefits of self-testing and use it more widely in their day-to-day study than in the laboratory;(77) however, this is not totally borne out by the evidence. For example, investigations of undergraduate learners’ real-world study behaviours indicate that appreciation and use of retrieval practice is low,(39,72) whereas, in at least one study,(82) medical students have been found to engage extensively in retrieval and distributed practice in the form of practicing multiple choice questions and flashcards in preparation for medical licensing examinations.

1.6       Flashcards as a learning and memory tool in medical education

Based on nearly 135 years of cognitive psychology research and a large body of evidence demonstrating high utility of retrieval and distributed practice for learning and memory, flashcards, which can incorporate both retrieval and distributed practice, are uniquely poised as a powerful tool to enhance learning and memory for learners in the medical profession where knowledge is expanding at an immense and unprecedented rate.(83) While incorporation of retrieval and distributed practice into medical curricula is limited,(82,84) by purchasing, creating, and/or sharing and using digital flashcards autonomously in self-regulated study,(85) health professions students(55,82,86–90) and medical residents(91,92) have found this tool feasible, desirable, and useful and have experienced its benefits over traditional tools.

Learning objects are a group of instructional materials structured to meet an educational objective, and digital learning objects have many advantages over traditional paper-based learning objects.(83) Flashcards are an example of learning objects. Note that traditional paper and modern digital flashcards inherently incorporate retrieval practice. While distributed practice with paper flashcards is possible (e.g., Leitner system), it would be extremely unwieldy as the number of flashcards increased; however, digital flashcards can easily exploit the benefits of distributed practice by building algorithms into the flashcard software that automatically calculate and implement spacing intervals for each flashcard based on the user’s learning progress. One such example of a digital flashcard application is Anki.

Anki is an open-source digital flashcard application that enables users to create, study, and share flashcards on their personal devices (phone, tablet, computer).(93) Anki is multi-platform, meaning that its app runs on Windows, Mac OSX, Linux/FreeBSD, and some mobile devices including Android and iOS systems. Anki is freely available on all these platforms except iOS, and is open source with an impressive library of add-ons created and contributed by its user community. AnkiWeb is a free extension to the application-based version of Anki that allows the user, in the absence of his/her personal device, to study his/her flashcards online. AnkiWeb also enables the user to keep his/her flashcards and study progress synchronized across multiple personal devices. Anki flashcards support text, images, audio, videos, and scientific markup. Anki’s distributed practice capability is via its embedded spaced repetition algorithm, which is based on an open-source algorithm from the proprietary SuperMemo flashcard program called SM-2 and can be traced back to its creator, Piotr Wozniak.(94)

Anki presents flashcards much like the traditional paper flashcard. The “front” of the flashcard containing the question is presented on the user’s screen. The user retrieves the information mentally and then taps or clicks the card to view the “back” of the card, which contains the answer for comparison to that which was mentally recalled. Based on the accuracy of the user’s mental recollection as judged by the user, the user then taps or clicks a selection from a menu of buttons that essentially tells Anki’s algorithm the difficulty level of that flashcard’s retrieval for this particular user at this particular time (e.g., forgot, difficult, good, easy). Anki then uses that information to calculate the spacing interval for the next retrieval of that flashcard, in essence, predicting how long it will take for the user to forget that flashcard and scheduling review of that flashcard immediately prior to this time and, thus, maximizing the retrieval-effort effect. Flashcards that are forgotten by the user are thus assigned shorter spacing intervals and reviewed more frequently, whereas flashcards that are easy for the user to recall are assigned longer spacing intervals and reviewed less frequently. The author explains this process from a constructivism view that can be thought of as Anki building and maintaining a digital representation of the user’s memory by forcing encoding exercises, triggering retrieval routes, and collecting data on the neurobiological process of consolidation occurring within the user in the interim. By modelling the user’s memory, Anki can intelligently and efficiently add to it and assist it in strengthening and improving itself.

Additional advantages of digital flashcards, specifically Anki, includes their portability, allowing the user to create and study flashcards on-the-go via his/her mobile device; their shareability, fostering collaboration and synergy for learning and memory between users; and customizability, permitting each user to personalize flashcard content, formatting, layout, and organization as well as edit content to ensure it remains contemporaneous with the current knowledge and best practices. The main drawbacks of digital flashcards, in the author’s experience, are the steep learning curve required to fully master their use in day-to-day learning and, therefore, reap their full benefits; the challenge of overcoming previously long and deeply engrained study habits, “tried and true” methods, and metacognitive beliefs about “what works best for me”; and the cognitive dissonance created by trading the aforementioned intuitive habits to rely on counterintuitive methods that feel slower and require more cognitive effort, even despite their being backed by nearly 130 years of cognitive psychology research.

Finally, Anki’s open-source design also enables access to user metadata by extraction and query of the user’s review log from Anki’s database. For example, for each flashcard review, one can determine when the review took place, the difficulty level of the flashcard as rated by the user at that review, the spacing interval that occurred previous to that review, the new spacing interval for the subsequent review, and the amount of time the user spent on the “front” and “back” of the flashcard at that review. For those interested in conducting research using Anki as a learning and memory tool, the utility of the metadata access is obvious.

1.7    Theoretical Underpinnings  

In order to match current formats of medical education, some medical educators have proposed that Bloom’s taxonomy of learning domains – cognitive, psychomotor, and affective – be redefined as knowledge, skills, and attitudes.(9,95) Note that I focus herein on the knowledge-based domain.(13) I will outline several applicable learning theories and concepts here.

1.7.1      Adult learning theories

Knowles suggested that adult learners learn differently than child learners in several respects and coined the concept of “andragogy” as the art and science of helping adults learn, in contrast to pedagogy.(96–98) In particular, key differences between adult and child learners are that adults have a different readiness and motivation to learn (e.g., I need to learn because my circumstances are changing. I learn because I want to.) and a different orientation to learning (e.g., Learning will help me deal with the situation in which I find myself).(13) Adults are interested in meaningful learning.(99) In general, it is only when adults understand a topic’s relevance that they will be willing to invest time into learning it.(9) Thus, linking basic science to scenarios encountered in clinical practice adds relevance to the basic science for the medical learner while simultaneously reinforcing and expending the cognitive conceptual coherence of the clinical science within the learner.

However, in medical education, to disregard all learning theories related to child learners would be premature – their lessons should be considered carefully. The educational journey through medical school and residency has many similarities to that of learning to read and process a new language. The sheer volume of new knowledge that the medical learner must acquire, retain, and have at-the-ready for transfer to real-world clinical scenarios is staggering. When second-grade children are learning to read, does reading words in context (contextual word training) act to further enhance reading development beyond that achieved by reading words in isolation (isolated word training)? I now review three learning theories from the child cognitive psychology literature related to reading, specifically word training,that may be applicable to the subject under consideration: the focal attention hypothesis, the contextual facilitation effect, and transfer-appropriate-processing approach to reading transfer.

1.7.2      Focal attention hypothesis

In the focal attention hypothesis, Samuels (1967) submitted that learning to read words is facilitated when the greatest amount of attention is focused on the orthographic components of the words.(100) It is thought that the requisite mental effort to convert letters into sounds builds stronger word representations in the memory.(101) It follows that cues received from context, despite facilitating more accurate word identification, actually detract from the print analysis and reduce long-term word retention.(102) In other words, context allows children to read more words but to learn fewer of them.(101) The corollary is that contextual word training, despite seemingly facilitating word acquisition, is more so a short-cut that reduces cognitive decoding effort for acquisition and, thus, does not facilitate long-term retention. Evidence supporting the focal attention hypothesis includes experiments that presented words alongside illustrations, within meaningful sentences, or as part of predictable stories and found lower word retention than when presented in isolation.(102) This seems to be related to the retrieval-effort hypothesis and how effortful learning produces durable learning.

The parallel to isolated word training might be flashcards that present basic science and clinical science separately and making no specific effort to integrate and interrelate these two areas of knowledge.

1.7.3      Contextual facilitation effect

The contextual facilitation effect refers to the observation that context serves as a self-teaching mechanism when performing word training,(102) that is, reading in context allows children to learn significantly more words than when reading words in isolation.(103) Children learning words in context have the greatest gains in accuracy, speed, and comprehension in comparison to children learning words in isolation.(104,105) Additional support for this effect includes evidence that contextual cues can be used by children as an aide to assist subpar decoding ability and, thus, offset deficient word analysis skills.(106)

The parallel to contextual word training might be flashcards that present basic science and clinical science in an integrated manner such that cognitive integration within the mind of the learner is fostered.

While it is clear that contextual word training has a definite advantage over isolated word training in terms of improved word acquisition, proponents of isolated word training have historically argued that the trade-off of contextual word training is inferior long-term retention; however, it is now apparent that the evidence they use to support this argument was flawed in that when traditionally testing retention, the tests administered were presenting words as a list, i.e., in isolation.(101,102,105) Measures of retention were confounded in previous experiments because words learned under both training conditions were only tested in isolation tasks. Indeed, more recent research has found that words learned via contextual word training are no more vulnerable to be forgotten than words learned in isolated word training when the testing task is taken into account.(102) Words learned in isolated word training are given an artificial advantage when recalled isolation because their encoding and recall tasks are similar. On the contrary, words learned in context and recalled isolation are disadvantaged because, in addition to being recalled, they are being transferred between two different tasks: from a contextual encoding task to an isolated recall task.(102)

This led researchers to take a closer look at not only word acquisition and word retention but also word transfer and the nature of the transfer testing task.

Note to self: This is consistent with the zone of proximal development (Taylor, 2013).

1.7.4      Transfer-appropriate-processing

Researchers observed that if a context exercise (e.g., reading a sentence) was the method of assessing word retention and transfer, contextual word training was superior, but if an isolation exercise (e.g., reading a list of words) was the method of assessing word retention and transfer, isolated word training was superior.(102) Thus, the transfer-appropriate-processing approach to word training states that words are read most accurately when the same cognitive processes are engaged during training and transfer tasks.(107) In other words, word transfer increases as the congruency between the training and transfer task increases, and word retention is facilitated when the encoding and retrieval processes are similar for word-specific representations in memory.(108) Therefore, words learned in context are less likely to be read accurately when subsequently encountered in isolation, and words learned in isolation are less likely to be read accurately when subsequently encountered in context. Since the end goal, real-world, transfer task for the majority of children is a context exercise, i.e., reading and comprehending a passage, contextual word training is superior in terms of word acquisition, retention, and transfer when compared with isolated word training. Given that words are rarely presented as a list in naturalistic reading, context word training enhances reading skill beyond isolated word training.(102)

The parallel in medical education seems to be that since the end goal of teaching basic and clinical sciences in medical school and residency is the recollection and use of these types of knowledge in clinical practice to solve and manage diagnostic problems (a context exercise), then the transfer-appropriate-processing training task should present, teach, and seek to format these types of knowledge in an integrated and contextual manner in order to enhance acquisition, retention, and transfer.

1.7.5      What makes a good flashcard?

The utility of flashcards as a learning tool, especially those that incorporate the techniques of both retrieval practice and distributed practice, is very high – this is based on almost 135 years of learning and memory research that show these two techniques to be superior than any other known techniques.(35,37) Surprisingly, despite this high utility and widespread use of flashcards in education for many years, the characteristics contributing to a high-quality flashcard has not yet been studied empirically as far as the author is aware. Tips for such characteristics have been proposed based on extrapolations from cognitive psychology research and vision research as follows.(85)

For retrieval-based learning activities, retrieval success is improved by short-answer format questions when compared to multiple choice questions(109) – this observation could translate into a simple maxim for formatting questions on flashcards: prefer short-answer questions and avoid multiple choice questions.

Research on the subject of cognitive loading indicates that when the learner’s working memory is surpassed by the cognitive load of a learning task, performance and learning is impaired. Working memory, limited to processing a finite number of informational elements at one time, presents a bottleneck for learning. Three types of cognitive load have been defined – intrinsic, extraneous, and germane. Drawing on cognitive load theory, various instructional techniques have been developed to minimize intrinsic and extraneous cognitive load in an effort to free up the maximum amount of working memory for the cognitive load most important for learning, that is, germane load.(110) Such instructional techniques could be applied to flashcards.

The expertise-reversal effect refers to the finding that instructional techniques enhancing learning among novice learners may not enhance and may even detract from learning among more advanced learners.(110) An extension of this effect may be that flashcards that are optimized for enhanced learning in novice learners may not be optimized for the same in advanced learners, vice versa.

Reading speed and accuracy is influenced by crowding between words horizontally and vertically.(111,112) Additionally, formatting font size, style, and color and use of bold, italics, and underline may direct and focus the learner’s attention on key concepts and thereby optimize the distribution of cognitive load.(85,113) Again, the application of these ideas to flashcards is feasible.

However, as far as the author is aware, no characteristics, including those that could be extrapolated from the above concepts, have been investigated in the context of flashcards. I submit that the characteristics making up a flashcard may impact knowledge acquisition, retention, and transfer.

The end… cliff hanger!

-AJ Kember


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Resistance, Impedance, and Pulsatility Index in Fetal Doppler

Below, a letter to the editor that I wrote in March 2019. My letter was ultimately rejected at the time because the said guideline was to be archived by the JOGC; however, as of today, 02AUG2019, the guideline still remains on the JOGC website and still remains in error. Nevertheless, others may find my musings below to be of some help, so I decided to publish the letter here.


Dear Editor,

This letter is regarding a corrigendum in the following SOGC guideline on the JOGC website:

The Use of Fetal Doppler in Obstetrics, No. 130, J Obstet Gynaecol Can 2003;25(7):601-7

In Table 1, “Factors affecting umbilical artery doppler flow velocity waveforms”, it states the following: “Increasing vascular impedance increases EDFV70” where EDFV is the “end diastolic flow velocity” and citation #70 is:

Surat DR, Adamson Sl. Downstream determinants of pulsatility of the mean velocity waveform in the umbilical artery as predicted by a computer model. Ultrasound Med Biol 1996;22:707-17

I believe this is in error.

The next line in Table 1 states: “Increasing vascular resistance decreases EDFV70-72”. While I am a relatively new trainee in obstetrics and gynaecology, this is what prompted me to investigate “resistance” and “impedance” as used in the context of describing vessel properties in Doppler studies. Are these terms synonymous, related, or not? As is, Table 1 would indicate that they are not synonymous and, in fact, very different – the mathematical implication is that they affect EDFV in an opposite manner. Initially, I was confused because my training and practice as a mechanical engineer taught me that, while not synonymous, these terms are related. Electrical “resistance” is the amount of opposition that a circuit exerts upon a current flowing through it when a voltage is applied to the circuit. In electrical theory, the term “resistance” is reserved for direct current (DC) circuits, and the term “impedance” was introduced in the 18th century to describe the concept of resistance in an alternating current (AC) circuit. Resistance is scalar, that is, it only has a magnitude. Impedance is a vector, that is, it has a magnitude and direction (phase angle). Impedance and resistance share the same unit to describe their magnitude, that is, the Ohm. However, magnitude alone is not sufficient to fully describe a vector, so impedance is expressed by use of a complex number in Cartesian form, which captures both magnitude and phase. By extension, for a DC circuit, the phase angle is zero, and the resistance and impedance are identical in this case only. So why does Table 1 indicate these two terms exert an opposing influence on EDFV?

In citation #70 by Surat and Adamson, an electrical transmission line analog model of sheep umbilicoplacental circulation was specified. Resistance was defined as “the opposition to steady flow through umbilicoplacental circulation… the ratio of mean driving pressure to mean blood flow.” Impedance was defined as “the opposition to pulsatile flow… the ratio of harmonic terms of pressure to the corresponding harmonic terms of flow.” While this paper explicitly concludes that increasing vascular resistance decreases EDFV, nowhere does it explicitly describe the relationship they found between vascular impedance and EDFV.

In cardiovascular fluid dynamics1, vascular impedance, Zi, is defined as the ratio of oscillatory pressure to oscillatory flow and is represented using complex numbers by the following equations (derivation not provided here for simplicity):

Real part

Screen Shot 2019-08-02 at 9.26.46 PM

Imaginary part

Screen Shot 2019-08-02 at 9.27.07 PM


Screen Shot 2019-08-02 at 9.28.26 PM

From the above equations, it is evident that vascular impedance and vascular resistance are directly related. Further, they demonstrate that impedance is indirectly proportional to the flow rate. Since we know that flow rate is directly proportional to velocity (equation not shown), it can be inferred that both impedance and resistance must be indirectly proportional to velocity. In conclusion, vascular resistance and vascular impedance should affect the EDFV in the same direction, i.e., in an inverse manner:

  • Increasing vascular impedance decreases EDFV, vice versa, and similarly,
  • Increasing vascular resistance decreases EDFV, vice versa.

In more familiar terms, it is commonly understood that the pulsatility index (PI) is a reflection of the impedance of the vessel to forward flow. The relationship between PI and impedance is one of direct proportionality, that is, as impedance to flow increases, the PI increases, vice versa. This relationship and the equation for PI is demonstrated:

Screen Shot 2019-08-02 at 9.30.21 PM

PSV = peak systolic velocity
EDFV = end diastolic flow velocity
Vm = mean velocity

From the above equation, one can see that as the EDFV decreases, the numerator increases, which increases the final quotient (PI) and, thus, the impedance, which again confirms the correct relationship between the vascular impedance and EDFV2.


-Allan Kember, MD, B.Sc Engineering
Resident, Department of Obstetrics & Gynaecology
University of Toronto


  1. Bergel DH. Cardiovascular Fluid Dynamics. London. Academic Press Inc. 1972.
  2. ‘Umbilical Artery Doppler Reference Ranges’, com, 2019, (accessed February 2019).

“Are you going to write something bad about us?”


If you are going to write a reflection on your international elective, here’s my advice.

(approx. 8-12 minute reading time)

Hi there. My name is Allan Kember. Welcome. I am a fourth- and final-year medical student at Dalhousie Medical School and an incoming resident in the Department of Obstetrics and Gynecology at the University of Toronto. I recently completed a five-week clinical rotation in the Obstetrics and Gynaecology Department at the Korle Bu Teaching Hospital (KBTH) in Accra, Ghana.

While I do enjoy writing, it requires time and effort – the former of which I lack. So I don’t tend to write unless I really need to. But after being approached by over two-dozen employees at KBTH about a foreign student’s recent reflection on KBTH, I feel that the time has come that I need to write something. The reflection was ignorant, insensitive, and insulting when read from the Ghanaian perspective. I can only hope that the reflection was in innocence and not malevolence, but regardless of the intent, damage was done. I have been in touch with the student’s school – a leader in the arena of global health – and have learned that an apology has been made and the situation has been sorted out.

The reflection went viral after my first week at KBTH. Almost overnight, I felt that the relationships I had built in my first week had suddenly changed. They became subtly guarded. When I introduced myself to staff I hadn’t met yet, they weren’t as enthusiastic about meeting this foreigner. I knew something had changed for the worse, but I didn’t know why. It wasn’t until I was starting a duty shift one night when I learned why. I had just greeted a nurse whom I knew well when, suddenly, a serious expression came over her face. “Are you going to write something bad about us?” She proceeded to tell me about the reflection, which I later found and read. This wasn’t the only time I was asked this question over the next four weeks. In my discussions with KBTH staff, I learned that many of them were deeply hurt by some of the statements in the reflection. My heart sank every time I was asked this question, but each time, it gave me an opportunity to allay any concerns and, thus, build stronger and deeper relationships with the KBTH staff, which is good, because one day I hope to visit them again.

For the remainder of this piece, I would like to give some advice for students who, having completed an international elective, intend to write a reflection about their experience. Note that much of this will be applicable to medical residents too. While I admit that I am not an expert, I have spent 12 months of my life immersed in various cultures with six of these months within three countries in Africa. As a researcher, I have also been involved in research in four African countries since 2013. Without further ado, my advice:

  • Role:
    • Always remember your role. You are not a doctor (unless you are a resident) – you are not there to “work” or “practice medicine”. You are not a news reporter – you are not there to write a thrilling story or earth-shattering exposé. You are not an auditor for the WHO or FDA – you are not there to assess safety or the standard of care. You are not a professor – you are not there to instruct the medical faculty how to do things better. You are not an explorer – you are not there for an adventure. No, you are a medical student – you are there to learn. Don’t forget that. Even if you are a medical resident, you are not likely there to “work” unless you are legally permitted to do so by the laws of the country you are visiting and have extended your liability coverage from home (e.g., CMPA).
    • Consider your choice of words carefully – it should reflect your role. If you were there as a learner, do not say, “I was working at KBTH.” Do not say, “I practiced medicine outside my home school and country for the first time.” Rather, you might say, “I was continuing my medical studies at.” Or you might say, “I completed a four-week elective clinical rotation at KBTH.” You weren’t “working”. You weren’t “practicing”. You are not a doctor (unless you are a resident or, in a unique situation, not a resident but holding an MD), and you do not hold a license to practice medicine in the country you were visiting. In fact, if you are a student, you do not even hold a license to practice medicine in your own country.
      • Note, however, that if you were conducting research, that is different, and you may have been “working”.
    • In remembering your role, it might be helpful to explain where you are in your medical studies in your introduction. Be cognizant that the medical education system in the country you visited may be very different than it is in yours. Medical school in Ghana is six years, so most Ghanaian readers would assume that a fifth- or sixth-year American or Canadian medical student is a senior whereas a third- or fourth-year student is a junior. However, it is important to note that medical school is only four years in the US and Canada, so a fourth-year student is a senior. This can muddy the waters, so it is important to give some context of where you are in your studies at home. This applies to residents too, for example, a residency in obstetrics and gynecology is five years in Canada and three years in Ghana; however, when the differences in programs are taken into account, it takes 13 years of post-secondary education in Canada to become an OB/GYN whereas it takes 14 years in Ghana.


  • Review:
    • If your intention is to make your reflection public (e.g., a blog post), do not publish it until you have had it reviewed and approved by several individuals.
    • First, you should have it reviewed by an individual with training and experience in cultural humility – the global health office at your school is a good place to look for such an individual.
    • Second, have it reviewed by your supervisor at the site where you completed your elective.
    • Third, I contend that you should also have it reviewed by your supervisor’s supervisor, i.e., the department head.
    • Do not publish your reflection until you have the approval of these three individuals at a minimum. If these three individuals have approved your reflection, there is a high likelihood that your reflection will sit well with the majority.
    • Note that this piece has been reviewed and approved by the above individuals (and more), so it is feasible.


  • Reflect
    • The reflection is about your experience. However, you need to also reflect on the language and sentiments you use to write about your experience.
    • While it may be semantics, I avoid using “low-resource setting”. While “low-income country” appears to be the chosen language of The World Bank, it does make me a bit uncomfortable to use it in a public setting and especially when conversing with my colleagues from abroad. Albeit, I am happy that we have moved away from terms such as “undeveloped”, “under-developed”, “developing”, and “third-world”. “Low-resource” is a bit condescending. I use “limited-resource.” The beauty of “limited-resource” is that it applies to every hospital in every country, hence the existence of the principle of justice (fair distribution of scarce health resources) in medical ethics. You can say that KBTH is a “limited-resource” setting, and you can say the same about the Mayo Clinic. One is more limited than the other, but that doesn’t change the fact that both have their limitations.
    • Do not label your elective site as “the most difficult of situations” and then proceed to tell your readers that if you could love your specialty in that situation, you could finally confirm that it is the right specialty for you. Not only is this incorrect (believe me, KBTH is not “the most difficult of situations”, and it is extremely unlikely that your school’s global health office will allow you travel to a country where such conditions exist), it is a blatant insult to all the staff at your elective site who happen to regard it as their place of employment – some for years, some for decades. Having sweat become an inescapable part of your life for a few weeks while on an elective in the tropics does not make it the most difficult of situations. Please!
    • Although your international elective may be a grand adventure in your mind, this really isn’t the most professional way to express or approach your international elective or medical education. An adventure is “an unusual and exciting, typically hazardous, experience or activity.” If you use this word, what are you implying about your elective site?
    • Be especially careful of the danger of a single story. It will be a great benefit to you if you watch the TED Talk called “The Danger of a Single Story” by Chimamanda Adichie. Remember that your reflection is painting a picture in the minds of your readers. If all they can imagine of Ghana is a scene of people wearing tattered rags for clothing amongst dilapidated and abandoned buildings, then you’ve told a single story and have led your readers astray. Far astray in fact. Over the past three years, I have spent more than two months living in Ghana, and most of the time, I feel underdressed. As a whole, Ghanaians are extremely well dressed – I contend, more well than my own culture.
    • Think about your privilege. Do not be ignorant of it. When you are ignorant of your privilege, you become entitled. The decor of pleasant words, no matter how generously applied, will fail to hide the reprehensible backdrop of entitlement from the minds of your readers.
    • Do not major on the negatives. Walking the tenuous line between accuracy and cultural sensitivity is likely the most difficult part of writing a reflection. Negatives can be found wherever one goes in the field of medicine – no matter the country or setting. The concept of relative disparity is helpful in understanding the ubiquitous nature of this phenomenon. Here is an example of majoring on the negative: the fact that patients’ families visit them at KBTH and stay nearby could be attributed to something negative by saying, for example, that family needs to be nearby in case the patient needs medication because they must pay for it out of pocket. But think about that for a second. If you were unwell and in the hospital, would you want your family nearby? Do patients’ families in Canada or the USA visit them while in hospital, bring them things, and help address any need they might have? Of course! There is a reason we call them “loved ones”. So there is no need to paint this fact in a negative hue. Further, virtually anywhere you go in the world (not just KBTH) you will learn that family is an integral part of patient care and that outcomes tend to be worse when family is not involved. A specific example from pediatrics includes “care-by-parent units”, which were invented in Canada by the internationally known and respected pediatrician, Dr. Richard Goldbloom.
    • Avoid making comparisons between the healthcare system at your elective site, with all its gaps, faults, disparities, and tragedies, with your flawless healthcare system at home (I am being sarcastic – while some are better than others, no healthcare system is perfect and all of them have their flaws). It is very tempting to make the “copy-and-paste” error, that is, copying what seems to work in a Western context and attempting to paste it somewhere else (e.g., West Africa) even if it isn’t feasible, applicable, culturally-sensitive, or sustainable. If you are going to make comparisons, you better invest a lot of time to do a lot of research to make sure they are fair comparisons. Obviously, there will be differences between healthcare systems in high-income, middle-income, and low-income countries. The reasons for these differences are extensive and incredibly complex – only a handful of intellectuals in the world can explain them adequately, so I advise to stay away from comparisons unless you have truly done your homework. Why not leave such analyses to organizations like The World Health Organization?
    • Check your facts. This isn’t always easy, so that is why review and approval by your site supervisor and the department head is imperative. If you don’t check your facts, you may end up repeatedly insulting one of the leading teaching hospitals in West Africa and its physicians, residents, nurses, and midwives! You may even imply, albeit indirectly, that they are incompetent in providing safe care. Further still, you may incriminate them as ones responsible for harming their patients. Be careful with what you state as fact. And, just for the record:
      • Ultrasound, imaging, and continuous fetal monitoring are available at KBTH and in Ghana – I saw all three used multiple times during my elective at KBTH.
      • Privacy is not a “luxury” at KBTH. This is why they have curtains and privacy screens available for use in every encounter. I set up the privacy screens and pulled the curtains dozens of times each day. Implying that something we take for granted in Canada and the USA is a “luxury” at KBTH contributes to driving a false wedge of disparity deeper and deeper into the minds of your readers who don’t know better (unless they are Ghanaian are are intricately aware of the situation on the ground there).
      • The blood bank is not notoriously empty at KBTH. Stating that the blood bank is notoriously empty may capture the interest of readers, but it is simply not true. After many duty shifts, unused blood is actually returned to the blood bank by the senior resident; however, in saying this, I wouldn’t want to detract from the age-old need for blood donors. While I was at KBTH, I saw a presentation by a senior consultant regarding the blood donation issue, and one new change that was implemented while I was at KBTH was that the blood bank began offering a blood donation site at the antenatal care outpatient department in order to streamline blood donation from patients’ family members.
    • IMPORTANT: A reflection is not the place to give a case-report. If you were to approach a major journal, for example, the BMJ, with a case-report, you would be absolutely refused publication if you did not have written informed consent from the patient. This refusal would be regardless of how well you anonymized the details of case. It is unethical to publish a case-report in a medical journal without written, informed consent of the patient, so why would it be any less unethical to do so in your international elective reflection?
    • Be very careful with sensitive issues. One such issue you will encounter is religion. I can almost guarantee you that religion and faith play a much greater role in the society at your elective site than it does in your home country. If you are not a person of faith, you likely have no idea how it feels to have the most precious thing you hold constantly belittled, trivialized, and demeaned by society around you. So when you dismiss the patient and her family’s faith and prayers as mere futility in order to make room for your all-knowing savior-doctor complex, you’re trampling underfoot not only this patient, but the majority of the population of Ghana. You are also forsaking your duty per the CMA Code of Ethics, Fundamental Responsibility #3: “Provide for appropriate care for your patient, even when cure is no longer possible, including physical comfort and spiritual and psychosocial support.” If you knew anything about the faith that your patient and her family holds so dear, you wouldn’t dismiss their acceptance of her prognosis as “odd”. Further, you wouldn’t conclude that their understanding of death and dying are a result of the poverty that is a way of life in Ghana. Ouch! That’s an utterly ridiculous conclusion! It implies that poverty takes the sting out of death. When the child of an impoverished mother and father dies, do you think they don’t grieve because they are poor, or in other words, because the value of their child’s life was somehow inferior to that of a middle- or upper-class child? Poor people grieve too. Dr. Paul Farmer once aptly stated, “The idea that some lives matter less is the root of all that is wrong with the world.” Poor lives matter, so don’t say that poverty makes suffering and death easier. Maybe take a look at Gutierrez on liberation theology and the preferential option for the poor. If you happened to ask this patient about her faith, perhaps you would learn that her acceptance of her prognosis may not be so odd after all.
    • Moving on now. You can’t speak the local language and you’ve had relatively little exposure to their culture, so don’t presume that you are in a position to evaluate patient-doctor communication.
    • Likewise, you are not in a position to evaluate the residents ‘and staff’s decision making. Stating that physicians at KBTH order the one test they think is the most important and then hope for the best is incredulous. First, it assumes that all patients presenting to KBTH can only afford one test – not true. Second, it implies that physicians at KBTH have tossed evidence-based medicine to the wind in favor of shooting from the hip – also not true. In fact, far from the truth. The consultants at KBTH happen to be board-certified by the West African College of Surgeons (at least 14 years of post-secondary education and training), so I’m not sure what gives a student the credentials to go about casting doubt on their clinical judgment. Further, don’t sensationalize the physical exam as if it is the only tool that doctors at your elective site have at their disposal. With the modernization of medicine, we are, both literally and symbolically, losing touch with our patients. In the dawn of artificial intelligence, perhaps watching the TED talk called, “A Doctor’s Touch” by Dr. Abraham Verghese would be helpful for any medical student who doubts the importance of the physical exam in his or her own practice.

Thanks for reading. Happy reflecting!


The Art of Medicine and the Science of Big Data

415727A reflection on my experience in the Division of Cardiac Critical Care at SickKids

27OCT2017                                                                                                (20 minute reading time)

From October 16th through 27th 2017, I had the immense privilege of completing an observership within the Cardiac Critical Care Unit (CCCU) at the Hospital for Sick Children (SickKids) in Toronto, Canada. I must admit that the CCCU was overwhelming in many aspects. Overwhelmingly complex, yet overwhelmingly specialized. Overwhelmingly busy, yet overwhelmingly efficient. Just imagine placing a four-year old into the cockpit of a Boeing 787 Dreamliner and telling him to, “Go for it. Take off, and deliver us to our destination safely.” I’m the four-year-old. The CCCU is the Boeing. Need I say more?

Established in 2006, the Division was the first of its kind in Canada. It has about a half dozen staff physicians, dedicated nursing and interprofessional staff, about a dozen fellows, and a 23 bed critical care unit. While rounding with the fellows and staff physicians, I saw and was taught about children with the most complex medical pathology in the country and witnessed the administration of commensurately advanced and ground-breaking treatments; however, although this would be an incredibly fascinating topic, it will not be the topic of my reflection here. Rather, I would like to reflect on the primary objective of my visit to SickKids: to interpose myself at the interface where critical care medicine meets data science and, thereby, learn about the application of data science in medicine. While I am a far cry from an expert in either field, I will attempt to share a few thoughts I have had over these two weeks including why big data in medicine interests me, why it should interest the medical community, and my perspective of the data science program at the SickKids CCCU.

My professional background is in mechanical engineering, and I’m currently completing my fourth year of medical school. Risking over-generalization, I will admit that my experiences in the classroom and clinic during medical school have taught me that the practice of medicine is more of an art than a science. As a trainee, I have not found peace with this notion but derive comfort in that, given time and practice, I will become a better artist. For the time being, I prefer the scientific approach to clinical problems, an approach inculcated during my training and practice as an engineer, an approach that is broad and multifaceted, team-oriented, step-wise, calculated, and endears a clear understanding of the background, problem definition, specifications, and real-world constraints. The scientific approach may not be time efficient but is incumbent upon trainees because they lack the knowledge and experience to approach medicine otherwise. I was introduced to helpful ideas related to this dilemma early in my medical training by two faculty members in particular.

First, Dr. David Haase, an infectious disease physician, taught me about the maturational pathway of trainees, which could be applied to any field of practice: we all begin as unconsciously incompetent and, with training, progress to become consciously incompetent, then unconsciously competent, and, finally, consciously competent. A trainee in the incompetent stages attempting to practice medicine as an art would be nothing short of guess work; trainees must take the scientific approach. As competence is gained over years of study and practice, the trainee matures, and the transition from the scientific to artistic approach becomes possible while maintaining a good outcome.

Second, under the tutelage of Dr. Pat Croskerry, a global pundit in critical thinking in medicine and the Director of the Critical Thinking Program at Dalhousie Medical school, I have come to appreciate the subject of metacognition, that is, thinking about how we think – remember, I am an engineer with no formal psychology background, so Dr. Croskerry’s lectures seemed quite novel to me. The two most important physician behaviors are knowledge and decision making, yet our decision making ability in medicine is unacceptably poor relative to other high-stakes fields, e.g., aerospace engineering. The diagnostic failure rate in medicine is approximately 15% and, accordingly, diagnostic error is by far the leading cause of medical harm resulting in legal action. Recognizing that at a fundamental level, how we think determines how we make decisions, Dr. Croskerry taught us about dual process theory, which I found quite helpful. Basically, when we think and make decisions, we operate between two systems: the intuitive (system 1) and the rational (system 2). System 1 is fast, informal, subjective, context-dependent, qualitative, and flexible. System 2 is slow, formal, objective, context-dependent, quantitative, and rigorous. As humans, we spend more than 95% of our time in system 1, which is where most heuristics, biases, and errors occur. The human mind is a cognitive miser, which refers to our tendency to take the path of least resistance in our approach to problem solving. The remarkable efficiency of system 1 enables this and saves many lives; however, it is a double-edged sword because system 1 plays a major role in medical error, which is the cause of a significant proportion of deaths, for example, 9.5% and 3rd highest cause of all deaths in the US according to a study from Johns Hopkins published in the BMJ in 2016. Trainees begin by functioning mainly in system 2 (rational) and eventually progress to system 1 (intuitive) as functions are repeated time and time again and pattern recognition develops. The systems can override each other, and we can toggle between systems in our decision making process, e.g., critically reviewing the history, physical, lab, and imaging data to “double check” my gut feeling that the diagnosis is pneumonia (system 2 overriding system 1), versus following my gut feeling and choosing to empirically treat this patient for pneumonia now because the context is so dire such that I cannot wait any longer to make a fully informed decision (system 1 overriding system 2). In either system, decision making can be compromised by fatigue, sleep deprivation, and cognitive overload.

I liken system 1 thinking to the artistic approach and system 2 thinking to the scientific approach. Ideally, all our decisions would be made in system 2 and, being the best decisions, would yield the best results; however, there are at least two problems with this. First, system 2 thinking is time consuming, which makes it impossible for the human brain, operating solely in system 2 and under extreme time constraints, to make the best decisions rapidly. Second, system 2 thinking is cognitively demanding, and this demand is amplified to exponential proportions as more variables are added to the problem (Hick’s Law postulates that time on a task is positively correlated with the number and complexity of choices), which makes it impossible for the brain to arrive at the best decision every time with an error rate of zero. Also, like the relationship between distance, velocity, and time, the time and cognitive requirements of system 2 thinking on the brain are not independent: increasingly complex problems (distance) demand increased cognitive effort, which, due to a limited cognitive processing speed so intrinsic to being human (velocity), forces a slower arrival at a decision (time). By extension, we can appreciate that system 2 thinking is less suited for high-acuity, time-sensitive, data-intense situations commonly encountered in critical care or emergency medicine, for example. Fortunately, system 1 thinking, with its best-selling feature of pattern recognition, allows us to overcome these two major supply-demand problems (time, cognition) and performs quite well most of the time.

So why the discussion about how we think and make decisions? Let me bring this back to why data science in medicine has piqued my interest. Given that we want to always make the best decisions all the time, let us assume that we can only think in system 2 – our decision making process would be formal and objective, but despite always making the best decisions, the time taken to reach our decision could be hours, days, months, or even years depending on the cognitive demand of the clinical problem. What if we could compress this computational time so that it was less than a second? Not only would it be fast, it would be faster than system 1 thinking. This is precisely where data science comes in, and this fascinates me.

With data science techniques, we can collect, process, and store huge amounts of physiologic data from our patients, including “real-time” variables and wave forms (e.g., heart rate and variability, respiratory rate, central venous pressure, systolic and diastolic blood pressure), lab values (e.g., hemoglobin, arterial blood gases, lactate, SvO2), and treatment parameters (e.g., ventilator settings, medication infusion rates). We can then use data science to develop patient risk analytics engines on this dataset, and these engines can then be used to collect, process, and analyze data simultaneously and enable healthcare providers to make the best decisions at the bedside. One such example is the inadequate oxygen delivery (IDO2) index by Etiometry, Inc. (Boston, USA), which received U.S. Food & Drug (FDA) 510(k) clearance in 2016. Using a software model of human physiology, the IDO2 integrates 18 measurements of 9 physiologic variables and Bayesian inference to continuously adjust the risk of inadequate oxygen delivery based on current and previously acquired data. The IDO2 index enables healthcare providers to rapidly, effortlessly, and accurately assess the likelihood that the patient is experiencing inadequate oxygen delivery defined as a mixed venous oxygen saturation (SvO2) less than 40% – intervention may then immediately ensue to prevent morbidity and mortality. By the way, critical care units are “oxygen-delivery-centric” – everything evolves around oxygen delivery. The IDO2 index was made possible by applying data science techniques to a huge data set – nearly 2,300 patients and over 10,000 measurements of venous blood gases – to develop the original analytical engine. The engine is now packaged with Etiometry’s FDA-approved software, T3 Data Aggregation & Visualization, which allows healthcare providers to collect, store, and visualize ICU data in essentially real-time at the bedside.

To think through such computations in system 2 thinking would take hours, days, months, or even years, so I have likened data science to a time warp. But it’s not like any time warp. This time warp is bipolar. By bipolar, I mean that it can be viewed as both a time dilation (slowing down of time) and a time contraction (speeding up of time) at the same time. As a time dilation, under the pressure of needing to make the best decision within a matter of seconds, big data allows us to consider the whole picture as if everything were in slow motion and we were thinking in system 2. As a time contraction, big data harnesses super-computing power to transform an analysis that would take us years to compute in system 2 into a matter of milliseconds, allowing us to make the best and maximally informed decision, now. Now, that is cool, but data science has much more to offer. Thus far, I have only discussed decision making as a response – a reactive process. What if, in medical decision making in the acute setting, we were able to transition from being passive and reactive (the traditional approach in the acute setting), to being predictive and active? What if, instead of letting things happen to us, we happened to things? For example, what if we were able to predict that our patient would have a cardiac arrest within minutes and, instead of the arrest happening to the patient, we happen to act within seconds to change the clinical course of the patient and prevent the arrest? Spoiler alert: we already can, kind of. Kennedy et al., (Houston, USA) are using time series trend analysis enabled by support vector machine algorithms to encode physiologic deterioration – a time dependent process – in PICU patients and thereby predict and prevent cardiac arrest (Pediatr Crit Care Med 2015;16:e332-e339). The data team here in the CCCU at SickKids is also using data science to build models that predict cardiac arrest. Now, that is super cool, and this sort of potential inherent in data science is expressly why the medical community, at large, should “listen up”.

It caught my ear in 2015 when Dr. Peter Laussen, Chief of the Department of Critical Care Medicine at SickKids, gave a grand rounds talk on data science in the pediatric CCCU at the IWK Health Centre in Halifax. After his talk, I stayed to chat with him about a similar vision that I had in the context of my global health work, and he graciously invited me to complete an elective rotation in data science at the SickKids CCCU. Now, I’ll share a bit about what I learned about the data science program within the CCCU.

I learned that thus far, data science is a very small component of the CCCU but, despite its small size, it is quite complex, increasing in magnitude, and gaining clinical relevance with time. Over a few years, the data science team has grown from one person with an idea to a multidisciplinary team of at least seven individuals from varied clinical, professional, and research backgrounds. The program is supported by only one full-time software engineer and three part-time data scientists, which was surprising to me.

How does the data flow from being a signal recorded by a device attached to or embedded in the patient to a data point in storage? From bedside to byte stored? In brief, the physiologic data collection devices (e.g., arterial lines, CVP line, BP cuffs, SpO2 probes, near infrared spectroscopy, respiratory flow transducers, thermometers) and the ventilator settings (e.g., PEEP, vent rate, Ppeak, TV, etCO2) are connected to a bridge that interfaces with a Philips IntelliVue bedside monitor. To date, aggregate infusion pump data inaccessible for proprietary reasons imposed by the vendor. The data displayed on the IntelliVue monitor is sent to the Philips central server via Ethernet, which then sends data to three places: a central monitor at the nursing station for monitoring in real-time by nursing staff not at the bedside, the electronic medical record (EMR) for charting of patient vital signs at regular intervals, and to the T3 (tracking, trajectory, and trigger) system allowing visualization of the patient’s current status and past course and the IDO2 by any healthcare provider at any computer with SickKids intranet connectivity and a secure hospital login. The data team also siphons all the data from the IntelliVue monitor via serial connection to a middleware medical device integration service called ViNESTM by True Process, which acts as a device gateway, streamlining the high frequency (500Hz) waveform, derived value, and device parameter data for intelligent and queryable storage before it is sent to the CCCU database. An additional source of data feeding into the CCCU database is the EMR, which ultimately links time-stamped laboratory values (e.g., arterial blood gases, lactate, hemoglobin) with the physiologic and device settings data. The EMR also feeds into T3 in the same manner, allowing for continuous visualization of trends and current time-synced physiologic monitor data, lab data, and device settings anywhere the user logs in. Very impressive.

I learned of a few barriers that the data science team has encountered in their journey thus far. From a human factors engineering standpoint, I’m told that something seemingly as easy as convincing CCCU staff (nurses and respiratory therapists) to connect the ventilator to the Philips bridge via an Ethernet cable when ventilation was initiated was much easier said than done. Eventually, the team achieved buy in, and this critical step is now routine practice in the CCCU. Lin et al., (BMC Medical Informatics and Decision Making (2017) 17:122) recently published a human factors study evaluating T3 in the SickKids CCCU to identify interface usability issues, to measure ease of use, and to describe interface features that may enable or hinder clinical tasks. The finding that I found most interesting by Lin et al., was clinicians’ mistrust in the IDO2 due to “lack of transparency and published evidence” – only one of seven clinicians in the study were familiar with what the IDO2 even was, which indicates that perhaps ignorance and lack of knowledge was more cause for distrust than the cited reasons. From the hospital systems management, ethical, and medicolegal perspectives, another barrier the team has faced includes the issue of prospectively collecting identifiable patient data, without consent from the patient or his/her substitute decision maker, for various clinical, research, quality assurance, and quality improvement purposes. What are the managerial, ethical, and legal implications of a data program and how can these be adequately addressed? Who knows at this point, but what I do know is that it is imperative for a budding data team to have an advocate with influence at the level of hospital management to help overcome these barriers.

I am not privy to the expenses associated with initiating and supporting the data science program, but I do know that the program runs on a very small budget, yet another barrier. One would think that a program with such unprecedented potential at a leading pediatric hospital would be well funded; however, remember that we are at the dawn of the interface between medicine and data science. Data science and medicine are two soon-to-be lovers that have only begun to embrace – the potential of what their relationship could produce remains yet unrealized. Like an overeager but well-meaning parent, the data science team has accompanied these two on their first date here in the CCCU. Medicine is responsible for paying the bill but is broke tonight for obvious reasons. The parents will have to float the cost for now, but it’s an expensive evening out and funds are tight at home.

Enough analogies. Although budget limitations can slow progress, it can make things more efficient, which is exactly what is happening at SickKids. I happened to be at the CCCU during a special time for the data science team. On October 19th, 2017, the team collected, processed, and stored their trillionth data point. A trillion is a million millions! 1,000,000,000,000! How do we store this much data? How many bytes would it occupy? How much would it cost us to store this much data? I don’t know the answers to these questions, but what I do know is that the CCCU data is securely stored at the Centre for Computational Medicine (CCM) shared by SickKids and the University Health Network in Toronto. The CCM boasts a 268 computer node cluster network with 34 terabytes of RAM and is capable of providing performance of 80 Gb/s steady throughput from the computer nodes to a 2.4 petabyte (1 petabyte = 1,000,000 gigabytes) storage cluster. Woah! The SickKids CCCU data team has access to the CCM, which allows for “distributive computing” – the computer-world parallel to “teamwork”, fitly expressed by the old adage, “many hands make light work”. Distributive computing is necessary given that data science operations on such colossal datasets require an enormous volume of computational power. Regarding the trillion data points – in its raw format, it would occupy a huge amount of memory (initial size: in the ballpark of 50 terabytes!), which would be prohibitively expensive to securely store using commercially available data servers; however, using a technique called “lossless compression”, the data science team has invented a novel way to compress the data they collect at a 100 to 1 ratio for space-efficient, cost-efficient, and readily accessible storage (final size: a mere 400 gigabytes!). With lossless compression techniques, no information is lost during the compression and, therefore, all the original information is exactly the same upon decompression. Incredible!

A few more points about the data science program:

Collecting data for machine learning purposes is distinct from collecting it for research or QA/QI purposes. With machine learning in mind, we must be much more diligent to minimize errors and ensure data continuity. Data quality and fidelity are not a given, so ensuring data quality is a job in itself. Also, for predictive analytics, you need to link what you are measuring to what you are trying to predict, which requires a secondary data collection stream of outcomes, which introduces yet another source of error: human error, e.g., digit preference, transcription error, labelling error. Interestingly, humans are not the only ones guilty of digit preference – I learned that the measurement devices we use have digit preference too.

We also need to be wary of systematic error introduced by a measurement device itself as this, by compromising data integrity and accuracy, could undermine every decision we make based on the data, whether clinical or research. One example is the arterial line blood pressure measurement, which is a second-order dynamic system possessing a natural frequency and damping coefficient influenced by multiple factors including the catheter, extension tubing, stopcocks, flush devices, transducer, amplifier, and recorder. Arterial line blood pressure measurement was first reported in the literature in 1949, and as the medical field adopted the technology over the subsequent decades, it was incumbent upon physicians to understand the physics underlying the technology and morphology of the blood pressure waveform it produced. However, in more recent years, having received little-to-no teaching on the underlying physics of waveform generation, students and staff healthcare providers pay little-to-no attention to the quality of the waveform and focus solely on the quantity (numbers) displayed next to the waveform, i.e., the systolic BP, diastolic BP, and mean arterial pressure (MAP). Relying on these values and ignoring the waveform morphology can lead to significant medical error. A “whip” waveform morphology indicates the system is under-damped and is overestimating the systolic BP and underestimating the diastolic BP. Conversely, when a clot forms in the catheter tip or air bubbles enter the extension tubing, the result is an over-damped system and can be recognized on the waveform by the loss of the dicrotic notch. My point is that although data science may perform system 2 thinking for us some day, this does not mean we can shut off our brains. Quite the contrary. We need to be more vigilant in understanding the tools we use. Data science is a powerful tool with unprecedented complexity, and, because inherent to its use are benefits and risks like any other medical treatment, it is critically important for healthcare providers that wield it to do so responsibly. This includes a good understanding of where, how, and how much error may be introduced and how this might affect outputs and thus our decisions – not an easy task in the face of an ever-widening chasm between two ever-specializing fields.

Finally, I learned that the data science program is truly a team effort at its core. I was impressed by the diverse, but complimentary, range of professional backgrounds that constitute the data science team. Drawing from various fields unrelated to healthcare, the team has made the data science program what it is today and has poised it well to have tremendous impact in the near future. On reflection, this diversity makes sense to me and is a necessity for the excursion the team is taking into uncharted territory. Mark my words, the SickKids CCCU data team is a team to watch.

In closing, I would like to extend a heartfelt thanks to Dr. Laussen, the data science team, and the Division of Critical Care for their warm hospitality over the past two weeks.

-Allan Kember

B.Sc. Engineering (Mechanical/Biomedical)

Med4, Dalhousie Medical School

GHIC 2017: To Yale and Back


Dear Reader,

This is a report of my experience at Unite for Sight’s 14th annual Global Health and Innovation Conference held at Yale University on April 22 and 23, 2017.

First, I will start off with my presentation of my Dalhousie Research in Medicine project, the Ghana PrenaBelt Trial. I presented my work on Saturday to a multidisciplinary, international audience of about 100 during the “Maternal, Child, and Family Health: Presentations by Student and Young Leaders in Global Health”. My co-presenters included four other medical students from Canada, the US, and Nigeria. My take-home points were that the PrenaBelt, when used during sleep throughout the third trimester, led to an increase in birth weight by about 100 grams when compared to a sham device, but this was not statistically significant. Also, informal education about back sleep in pregnancy by midwives combined with an intervention to prevent back sleep (whether the PrenaBelt or sham-PrenaBelt), led to a statistically significant increase in birth weight (by 107-153 grams), greater gestational age at delivery (by 6 days), and a lower rate of preterm delivery (4X less likely) than a non-interventional, non-back-sleep-educated control group. My presentation was well received. However, it was not until the “Innovation & Ideas Evening Networking Reception” later, that I received some very positive and encouraging feedback from four Indian neonatologists. They had missed my talk (due to many co-occurring sessions), but were asking about my work. I had my presentation on my iPad and gave them a brief version of my talk, engaging them in discussion at the same time. They were especially intrigued about my secondary outcomes, which I had glossed over pretty quickly during my talk earlier that day, namely, the gestational age at delivery and preterm delivery rate differences between the interventional and non-interventional groups. As a result of this conversation, I will be taking a closer look at these results. Multivariate logistic regression is also underway.

Regarding the presentations, here are a few remarks that were memorable.

During her keynote, Vanessa Kerry, mentioned the moral dilemma of how 80% of journal publications on HIV research in Africa have a Western investigator as the lead author. In academia, our personal and professional promotion are contingent, at least in part, to being the lead author (on as many papers as possible); however, we must be careful not to exploit our collaborators for our own interests, without whom we could do nothing. The locus of control must be theirs. They must have and feel the ownership of the work. All of this is making me re-think the authorship order that I had in mind for my team’s work in Ghana.

The most innovative idea I saw at GHIC was NeMo (“Neonatal Monitoring”), which is a simple device that empowers mothers to identify neonatal danger signs within the first week of life to prevent neonatal mortality. NeMo was designed by Rachel An and her team at Johns Hopkins University. It involves educating the mother of 4 warning signs and also a sensor on the neonate that continuously records the respiration rate and temperature, which is transferred to an app on mom’s phone and sounds an alarm if these parameters meet a set threshold. I think it has great potential due to its simplistic nature and low cost (50 cents).

I was happy to meet a couple medical students from the University of British Columbia. It seems that the global health program at UBC is quite “sexy” (i.e., popular). UBC has a partnership with the government of India, and Med2 student, Shandel Riedlinger, was a co-presenter during the session in which I presented. She presented on the UBC project investigating anemia in school-aged children living in the Indian Himalayas. I was impressed by UBC’s initiative to have their Med1’s working with their partners in India so early on in their medical program. Apparently, this particular initiative is quite popular and thus involves a competitive application process. It would be nice to see Dalhousie form a similar research collaboration with an LMIC government or institution. Notice that I said “research”. At this point, I am going to go on a rant:

Twice at GHIC, I heard presenters (one a keynote, and one a medical resident) say that if medical trainees (whether students or residents) think they can justify participation in “international work” or “global health”, they are only deceiving themselves and causing more harm than good and that this is an immoral practice that must be stopped. I have heard this sentiment before in a variety of settings. I have a problem with it because it uses such a wide brush to paint ALL medical trainees involved in global health as medical voluntourists attempting to build their CVs and egos at the expense of the world’s poor, which is not true. Had these presenters attended the “Student and Young Leaders in Global Health” sessions they would have learned that none of the presenters were actually involved in clinical work abroad. On the contrary, almost every presenter was involved in a supervised, productive, enduring, North-South, research collaboration assisting LMIC clinicians and health care workers answer their locally-generated research questions. The presenters had written and won grants to support the research of their LMIC partners, personally assumed the expenses to travel to the countries of their partners, and invested their own time and research expertise on assisting with data analyses and publication. There is a world of difference between trainees involved in global health research collaborations (helping the locals) versus global health clinical electives (potentially harming the locals). Saying that all medical trainees participating in global health work are “deceiving themselves” and “causing more harm than good” is an ignorant generalization and a slap in the face to many, like myself and my co-presenters at GHIC, who sacrifice more than ever gets told or recognized on behalf of our LMIC partners and the population they serve. I assure you that our LMIC partners would agree and be the first to stand in our defense. For trainees who are considering the contentious practice of global health electives and medical voluntourism, Jane Aronson put it well at GHIC: “You have a moral duty to volunteer, BUT you have a greater moral duty to be a trained volunteer.” End of rant.

The most important take-home message from the conference for me personally was said by Jordan Levy of Ubuntu, “You cannot create deep impact without first taking care of yourself… you bear the immense weight of responsibility in social change… You are the engine behind social change – take care of that engine.” This issue of self-care versus the personal sacrifice incumbent in global health work came up again in the “Leadership and Management Strategies Panel”. Richard Skolnik recounted how in his work at the World Bank, he has traveled 125 days of the year for 25 years, made 91 trips to India, been in several accidents and bombed, contracted hepatitis, almost died from a GI bleed, and so on. He emphasized that we often view global health heroes as if their lives are perfect but that a tremendous amount of hardship will remain forever untold. “Global health work”, he said, “is not healthy.” The take-away is that “job one” is to take care of one’s self. Wise and timely advice. Point taken.

The most touching account at GHIC was told by Chris Underhill at the “Integrity in Global Health and Innovation Plenary Panel”. Early on, the panelists made it clear that despite their being chosen as panelists on a session about integrity, they had by no means been perfect examples themselves. They were asked to elaborate. Chris proceeded to tell a story how early in his career, he was visiting a hospital in Haiti. He got lost in the hospital, and while wandering the halls, he encountered a cage in which five mentally ill men were locked. There was a group of boys torturing the men by poking sticks at them through the bars in the cage. Chris said, “At that stage of my life, I didn’t know what to do, so I did as told in the famous account many here will be familiar with – I ‘passed by on the other side’.”  Of course, he was referring to the account of the Good Samaritan told by Jesus in Luke 10:25-37. Chris continued, “It was later that I grabbed mental health with two hands!” Integrity is doing the right thing regardless of who is watching.

In closing, I would like to quote something Richard Skolnik said during the integrity panel that resonates with my own circumstances. A warning. “No NGO had failed because they focused their work. They failed because they violated Management 101 and tried to do too much too soon.” How true. It reminds me of something a mentor said to me a few months back, “Be careful about collaborating when you should be consolidating – especially if you have a limited capacity to manage.” Point taken again.

I must say that GHIC 2017 was an tremendous opportunity to learn and network, and I hope to attend again at some point in the future. Special thanks to my team in Ghana, Canada, Australia, and USA. Special thanks to my funders, Grand Challenges Canada (which is funded by the Government of Canada) and the Dalhousie Medical Research Foundation. Finally, special thanks to the JJ Carroll Travel Fund for financial support of my trip to GHIC 2017.

All for now,


End-of-2016 Update


Dalhousie students collaborating with Dr. Jerry Coleman (Korle Bu Teaching Hospital, Accra, Ghana) at Just Us Cafe near Dalhousie Medical School. From left to right: Emily, Jon, Mike, Dr. Coleman, Allan, and Sarah.

It has been over a year since I posted on here. Shame on me. A lot has happened. One reason that I haven’t posted anything here is that I had decided to focus more on the GIRHL website. I built a couple pages there and wrote a few blog posts. Here’s one of the pages: Meet the PrenaBelt Team! The other page I built was retired.

Highlights of 2016:

  1. Dr. Coleman came to Halifax for the month of May to train in fetal ultrasound at the Fetal Assessment Treatment Centre at the IWK Women’s Health Centre. He also presented the interim results of the Ghana PrenaBelt Trial at the 2016 Bethune Round Table in Halifax, NS.
  2. We completed the Ghana Prenabelt Trial in July. I worked on the analysis from July through September. We submitted our Final Report to the Ghana Food and Drugs Authority in September.
  3. We launched the KBTH-GIRHL Healthy Birth Weight Study in April, which is a cross-sectional study that will complement the results of the Ghana PrenaBelt Trial. This study is slated to be completed in January 2017.
  4. Dr. Warland and her team presented the Australia PrenaBelt Trial results at 4 international medical conferences. These results are very intriguing. Dr. Warland visited our team in Halifax in September to present her team’s research at a Grand Rounds at the IWK and brainstorm next steps.
  5. The Halifax PrenaBelt Trial launched in the spring of 2016 and is slated to be completed by January 2017. Interim results (October) were promising.

All for now. Gotta run! Stay tuned in 2017 as we have several interesting conference presentations planned. We also plan to complete all the analyses and release/publish our results.

Thanks to our funders: Grand Challenges Canada, Dalhousie Medical School, University of South Australia School of Nursing and Midwifery


Why I want to fix obstetric fistula – by Allan Kember

Here is a link to a ~2 page article I wrote on “Why I want to fix obstetric fistula” for the DalMed Global Health Interest Group. Well, I didn’t write it for the DalMed GHI, but I published through them. I wrote it more for myself because sometimes it helps to write one’s thoughts down.

I will check the link periodically to make sure it continues to work properly. If there are issues, I will just publish the post on this blog.

Update: Recruitment for the Ghana PrenaBelt Trial is 25% Complete!

October 11th, 2015

Greetings! It is with great excitement that I write this update. Ever since my team secured authorization from the Ghana FDA on August 14th, 2015 to conduct our clinical trial in Ghana, things have been moving at a lightning pace.

While I settled in to my second year of medical school back in Halifax, Dr. Jerry Coleman, our Principal Investigator at the Korle Bu Teaching Hospital, conducted some final meetings with his team in late August and early September. On September 7th, 2015, Dr. Coleman and his team successfully launched the Ghana PrenaBelt Trial – a double-blind, sham-controlled, randomized controlled trial investigating maternal back sleep in late pregnancy as a potential modifiable risk factor for stillbirth and low birth weight.

Dr. Coleman’s clinical team – made up of four midwives – is working daily and diligently in the antenatal care clinic to invite, screen, consent, enroll, randomize, and interview participants. It is a colossal task, and they are doing an exemplary job! During the first week of the trial, the team recruited two participants per day on average. By the second week, the average was four participants per day. I am happy to announce that the team has reached our first milestone of 50 participants recruited! Given that our target sample size is 200 participants, recruitment is 25% complete. The participants are eager to use the PrenaBelt every night. Family are engaged too – several participants have reported that their husbands are encouraging and reminding them to wear the PrenaBelt every night! A special thanks to our midwives: Josephine Kwaw, Rose Quartey, Jemima Marfo, and Joyce Dodoo.

Dr. Coleman and I have been having weekly meetings via Skype to debrief on progress and discuss any issues. He has expertly managed everything related to the trial and team to date – props to him! Maxfield Okere is our Data Lead in Ghana. Maxfield has been remarkably proficient in managing all the data related to the trial. The data team is completed by my Project Coordinator in Halifax, Jesse Wells (GIRHL), and our newest addition to the PrenaBelt team, Sarah MacRitchie (GIRHL). A hearty thanks to the data team!

My co-investigator and mentor, Dr. Heather Scott (IWK Women’s Health Centre), visited the team at the trial site in Ghana from September 26th through the 30th, 2015. The visit was of mutual benefit. The team was thrilled with the opportunity to meet and get to know Dr. Scott, vice versa. Dr. Scott was able to see the recruitment process from start to finish and work along side the clinical team. Relationships between Ghana and Canada were strengthened and will hopefully continue to grow in weeks, months, and years to come. I am deeply indebted and grateful to Dr. Scott for her alacrity in setting aside the million other things she has going on and travelling almost 8,000 kilometers for this project!

Finally, I am excited for my co-investigator, Dr. Ali Borazjani (GIRHL), as he prepares to visit the team at the trial site in late October through early November. Hopefully, I will have another update for you after Ali’s visit!



Project Lead
A maternal device for the prevention of stillbirth and low birth weight
This project is supported by Grand Challenges Canada, which is funded by the Government of Canada.

Midwives Jemima (left) and Josephine (right) delivering an introductory and instructional session to newly recruited participants.

Midwives Jemima (left) and Josephine (right) delivering an introductory and instructional session to newly recruited participants.