the hidden curriculum

1. The Hidden Curriculum Faculty Development UBC Family Practice Postgraduate Program Welcome to this module on the Hidden Curriculum. This session is meant to be interactive, especially since the hidden curriculum is a changing one in our medical culture. Hopefully this module will spark some interesting discussion. Welcome to this module on the Hidden Curriculum. This session is meant to be interactive, especially since the hidden curriculum is a changing one in our medical culture. Hopefully this module will spark some interesting discussion.

2. Before defining this mysterious term, let�s start by asking a question: Have you, as a preceptor, caught yourself committing some of the awful things you swore you would never do? Would anyone feel comfortable sharing a story?.. Maybe that wasn�t the gentlest way to break the ice in a group� Perhaps we can depersonalize the question a bit: during your training, do you remember a preceptor doing something you swore you would never do?Before defining this mysterious term, let�s start by asking a question: Have you, as a preceptor, caught yourself committing some of the awful things you swore you would never do? Would anyone feel comfortable sharing a story?.. Maybe that wasn�t the gentlest way to break the ice in a group� Perhaps we can depersonalize the question a bit: during your training, do you remember a preceptor doing something you swore you would never do?

3. Case 1 Man in early 20�s, IQ 160, Dx: TB Psychologist noted subtle changes in mental status. Feared TB entered CNS, alerted clinical clerk Clerk phoned attending: attending hung up Chased resident down the hall �What�s the point? We did a neuro consult. They gave him a clean bill of health. So some half-assed psychologist thinks otherwise.� Next pt encounter: near-catatonic state� irreversible Charles LeBaron, Gentle Vengeance Just to make us feel a bit better about ourselves, here is an example of one of those instances:� The point here is not to lay blame. The truth is, as preceptors, we need to remind ourselves that there is simply a lot more to teaching than meets the eye. That is, when we teach, even informally, we are delivering a curriculum of sorts. But by the way we teach, we are also teaching the values, morals and the �code of conduct� of our medical culture. This is what we mean by the �hidden curriculum� Just to make us feel a bit better about ourselves, here is an example of one of those instances:� The point here is not to lay blame. The truth is, as preceptors, we need to remind ourselves that there is simply a lot more to teaching than meets the eye. That is, when we teach, even informally, we are delivering a curriculum of sorts. But by the way we teach, we are also teaching the values, morals and the �code of conduct� of our medical culture. This is what we mean by the �hidden curriculum�

4. Case 2 On the third day post-op fractured hip repair a 72 year old woman is switched from morphine to acetaminophen and codeine for pain. (routine orders) Later that day the family practice resident notes that the patient seems to be in a lot of pain with little relief from the T#3. The senior surgical resident sees the patient and finds no infection or other problems and tells the FP resident that the patient is fine. The FP resident checks the chart but avoids the patient because she is uncomfortable and the encounter is unpleasant. The patient spends 6 days in uncontrolled pain before it gradually settles on its own. Here is an example which seems a little less extreme, but unfortunately, not uncommon� What has happened here? The family practice resident is the �low man on the totem pole� in this clinical situation. She, however, has responsibility to assess the patient. In trying to address the patient�s concern (pain) she is redirected to address the fracture, possible complications and charted vital signs. Perhaps this patient does not metabolize codeine and gets no analgesic benefit? She defers to her �superior�. She learns to avoid patient centred care. Here is an example which seems a little less extreme, but unfortunately, not uncommon� What has happened here? The family practice resident is the �low man on the totem pole� in this clinical situation. She, however, has responsibility to assess the patient. In trying to address the patient�s concern (pain) she is redirected to address the fracture, possible complications and charted vital signs. Perhaps this patient does not metabolize codeine and gets no analgesic benefit? She defers to her �superior�. She learns to avoid patient centred care.

5. Outline Red flags (warnings) that our current medical culture has problems. The history of these problems in our medical culture. Implications of our medical culture on intellectual and emotional development. Consequences of introspection and dehumanization This module is meant to address a number of issues. There are �red flag� statistics which indicate problems within our medical culture affecting physicians and their learners. We will look at the history behind these problems and the implications of these problems on our learners. Finally, we will explore the dangers (and fears?) of introspection and dehumanization. This module is meant to address a number of issues. There are �red flag� statistics which indicate problems within our medical culture affecting physicians and their learners. We will look at the history behind these problems and the implications of these problems on our learners. Finally, we will explore the dangers (and fears?) of introspection and dehumanization.

6. Red Flags 1 In traditional medical culture medical culture, the staff physicians teach the senior residents, the senior residents teach the junior residents, and the junior residents teach the clerks. Most medical schools and residency programs have not formally given instruction on how to teach. Faculty Development programs attempt to address this issue. These red flags may indicate that we are not teaching our learners some of the basics of being a doctor. In traditional medical culture medical culture, the staff physicians teach the senior residents, the senior residents teach the junior residents, and the junior residents teach the clerks. Most medical schools and residency programs have not formally given instruction on how to teach. Faculty Development programs attempt to address this issue. These red flags may indicate that we are not teaching our learners some of the basics of being a doctor.

7. History Education Behaviour training at par with teaching knowledge Assumption that appropriate behaviour follows appropriate knowledge Patient Perceptions Deficiency in ability Deficiency in character This is not a new problem. It is the result of a long trend in history. Early records show that learning how to behave was given equal measure to learning knowledge in the healing professions. (2). Slowly this pattern changed to the point where, now, proper behaviour is simply assumed to naturally follow the transmission of knowledge (2, 3). Interestingly, there has been a parallel trend in the history of medicine from the patients� point of view, in terms of their disappointment in physicians. In our earliest records disappointments were generally regarding a deficiency in physicians� ability (2). There has been a remarkable shift from these kinds of disappointments to disappointments in physicians� character (4, 5, 6). The assumption that is made regarding proper behaviour, therefore, seems to be a very dangerous one, especially when combined with the values of our medical culture. This is not a new problem. It is the result of a long trend in history. Early records show that learning how to behave was given equal measure to learning knowledge in the healing professions. (2). Slowly this pattern changed to the point where, now, proper behaviour is simply assumed to naturally follow the transmission of knowledge (2, 3). Interestingly, there has been a parallel trend in the history of medicine from the patients� point of view, in terms of their disappointment in physicians. In our earliest records disappointments were generally regarding a deficiency in physicians� ability (2). There has been a remarkable shift from these kinds of disappointments to disappointments in physicians� character (4, 5, 6). The assumption that is made regarding proper behaviour, therefore, seems to be a very dangerous one, especially when combined with the values of our medical culture.

8. Admission to Medical School Intellectual Fitness FIRST Then screen for emotional fitness and character. Once admitted the student must then be ACCEPTED into the medical culture. Let�s take a look at how these values are passed on through our culture. One anthropologist-turned-medical-student stated that he observed tribes in the remote jungles of Africa who had cultures less foreign to him than what he experienced in the medical world! His observations started with the process of admission (7). As most people know, the process of admission into medical school is quite rigorous. Academic success and intellectual fitness carries tremendous weight. Once a �short list� of candidates are set, they are scrutinized for their character and emotional fitness. Then they are admitted into medical school! However, after admission there comes another step: to be accepted into the medical culture. The student looks to his teachers and �superiors� as a model for his or her behaviour. They quickly learn the values of those ahead of them. Let�s take a look at how these values are passed on through our culture. One anthropologist-turned-medical-student stated that he observed tribes in the remote jungles of Africa who had cultures less foreign to him than what he experienced in the medical world! His observations started with the process of admission (7). As most people know, the process of admission into medical school is quite rigorous. Academic success and intellectual fitness carries tremendous weight. Once a �short list� of candidates are set, they are scrutinized for their character and emotional fitness. Then they are admitted into medical school! However, after admission there comes another step: to be accepted into the medical culture. The student looks to his teachers and �superiors� as a model for his or her behaviour. They quickly learn the values of those ahead of them.

9. Demonstrating our Values As preceptors and mentors, we constantly display our values. How does your resident view your attitude to your work? Does your resident see you as bored or disenchanted with your work, for example?As preceptors and mentors, we constantly display our values. How does your resident view your attitude to your work? Does your resident see you as bored or disenchanted with your work, for example?

10. Admitted but not yet Accepted Proving your �Intellectual Fitness� In terms of the intellectual challenge, Do you have any examples of feeling you had to prove your intellectual fitness to practice medicine? Consider the following example. In terms of the intellectual challenge, Do you have any examples of feeling you had to prove your intellectual fitness to practice medicine? Consider the following example.

11. Case 3: Intellectual Fitness Learning session on heart sounds Student A: �Well, I think I heard S1 and S2... There might have been a systolic murmur...� Preceptor Response: � I�m not interested in your opinion. You are to report your findings. Did you hear the heart sounds or did you not?� Student B: confident report Preceptor Response: � You know, I don�t even care if you�re wrong. That was perfect.� Here is an example that speaks to the concept of intellectual fitness. One week, a group of students set out to learn how to auscultate a patient�s heart. After carefully listening, one student reported to his preceptor: �Well, I think I heard S1 and S2... There might have been a systolic murmur...� The preceptor interrupted, and said: � I�m not interested in your opinion. You are to report your findings. Did you hear the heart sounds or did you not?� A second student auscultated the patient�s heart, and confidently stepped forward, saying she heard this sound and that sound, and this was the kind of murmur the patient had. Now the student was actually wrong on one account. The preceptor�s reaction was: � You know, I don�t even care if you�re wrong. That was perfect.� (8) What was the lesson here? What did the students take away from this? Did the student learn that being confident was more important than being correct? Did he learn that it is not acceptable to admit a lack of knowledge or weakness? Can you recall similar experiences in med school/residency? There is no doubt that what was learned that day had very little to do with auscultation technique, or even heart sounds in general. Rather, the message taken home was that confidence, whether merited or not, is a tremendous asset in medicine. The disturbing implication is that confidence without foundation; that is, the air of superiority that exceeds merit, seems to be a definition for another word; that word is arrogance.(9) Here is an example that speaks to the concept of intellectual fitness. One week, a group of students set out to learn how to auscultate a patient�s heart. After carefully listening, one student reported to his preceptor: �Well, I think I heard S1 and S2... There might have been a systolic murmur...� The preceptor interrupted, and said: � I�m not interested in your opinion. You are to report your findings. Did you hear the heart sounds or did you not?� A second student auscultated the patient�s heart, and confidently stepped forward, saying she heard this sound and that sound, and this was the kind of murmur the patient had. Now the student was actually wrong on one account. The preceptor�s reaction was: � You know, I don�t even care if you�re wrong. That was perfect.� (8) What was the lesson here? What did the students take away from this? Did the student learn that being confident was more important than being correct? Did he learn that it is not acceptable to admit a lack of knowledge or weakness? Can you recall similar experiences in med school/residency? There is no doubt that what was learned that day had very little to do with auscultation technique, or even heart sounds in general. Rather, the message taken home was that confidence, whether merited or not, is a tremendous asset in medicine. The disturbing implication is that confidence without foundation; that is, the air of superiority that exceeds merit, seems to be a definition for another word; that word is arrogance.(9)

12. Admitted but not yet Accepted Proving your �Emotional Fitness� Just as we scramble to conceal our ignorance, we physicians are also guilty of concealing our emotions. Can anyone can think of an example where you or a colleague or a learner felt they had to prove themselves as �emotionally fit� to practice medicine? Was this modeled to you? Any explicit or implicit messages?Just as we scramble to conceal our ignorance, we physicians are also guilty of concealing our emotions. Can anyone can think of an example where you or a colleague or a learner felt they had to prove themselves as �emotionally fit� to practice medicine? Was this modeled to you? Any explicit or implicit messages?

13. Case 4: Emotional Fitness I think it is very ugly that this lab should come along so early in my medical education� Isn�t there something wrong with starting off by causing pain without an intention to cure?� Meanwhile�the students� are beginning to say� �How are you ever going to be a doctor if you�re too sensitive to do dog lab?�� It�s a confirmation of all my worst suspicions - this lab is intended to toughen me, to divide me from ordinary normal people. P. Klass, A Not Entirely Benign Procedure p.30-33 Here is a pretty clear example of how students had to conceal their emotions. Back in the 1980�s in Harvard University, students were asked to do a cardiovascular lab. The lab involved running experiments on a live dog. By the end of the lab, the students supposedly emerged with a superior grasp of the workings of the cardiovascular system. The dog, of course, died. This is the response from a student who refused to do the lab.Here is a pretty clear example of how students had to conceal their emotions. Back in the 1980�s in Harvard University, students were asked to do a cardiovascular lab. The lab involved running experiments on a live dog. By the end of the lab, the students supposedly emerged with a superior grasp of the workings of the cardiovascular system. The dog, of course, died. This is the response from a student who refused to do the lab.

14. Case 4: Emotional Fitness I went upstairs� took a shower. But nothing could� get that doggy smell out� I sat down on my bed� And thought�You came to medical school to learn how to heal people, save them pain�But if you do wake up somewhere years from now and much to your amazement they want explanations for why you tortured and killed a dog today, you better get your story all good and rehearsed because you�ll have a lot of explaining to do. C. LeBaron, Gentle Vengeance, p. 191 Some students were persuaded to do the lab. Here�s one account: First there�s a general stirring of limbs. Then she twists her head around and looks at me. Our eyes meet. Then she starts howling. The hubbub in the room collapses to aghast silence, everyone is frozen in movement, and the howling continues, horribly loud in that sudden emptiness. The instructor rushed to the scene, re-anesthesized the dog, and explained: It didn�t wake up� That�s a reflex� yes, don�t worry about it. She wasn�t feeling any pain.�This happened once more, this time the dog weakly tried to bite the student�s hand. Two other dogs also awoke and mournfully howled before the lab was over. Many students deemed this the most valuable experience in physiology. But here�s another, more private response. Some students were persuaded to do the lab. Here�s one account: First there�s a general stirring of limbs. Then she twists her head around and looks at me. Our eyes meet. Then she starts howling. The hubbub in the room collapses to aghast silence, everyone is frozen in movement, and the howling continues, horribly loud in that sudden emptiness. The instructor rushed to the scene, re-anesthesized the dog, and explained: It didn�t wake up� That�s a reflex� yes, don�t worry about it. She wasn�t feeling any pain.�This happened once more, this time the dog weakly tried to bite the student�s hand. Two other dogs also awoke and mournfully howled before the lab was over. Many students deemed this the most valuable experience in physiology. But here�s another, more private response.

15. Case 4: Emotional Fitness �� I�m allowed little time to squander on such mawkish reflections. In the twinkling of an eye, it�s midterm week, four exams in jackhammer succession.� C. LeBaron, Gentle Vengeance, p. 191 One may think that the �dog lab� is fairly outdated, but as of March 2007, 14 medical schools across the USA were still running the lab (12). Whether you think that it is a thing of the past or not, the following statement from the student was anything but outdated. One may think that the �dog lab� is fairly outdated, but as of March 2007, 14 medical schools across the USA were still running the lab (12). Whether you think that it is a thing of the past or not, the following statement from the student was anything but outdated.

16. - Frederic W. Hafferty �Introspection and reflection are terminal diseases in medical school.� With this experience in mind, one can see the truth in our anthropologist�s (Hafferty�s) statement that: �Introspection and reflection are terminal diseases in medical school.� (7) The popular case-based curriculum which now dominates most medical schools in Canada is a much more merciful curriculum than the previous lecture-based model. But regardless of what curriculum you go through, there is still a never-ending and life-long scramble to learn medicine. We therefore must learn to prioritize, and prioritize we do, according to the values of our culture. Even simple observation of how the hierarchy functions can teach us the values of our culture. With this experience in mind, one can see the truth in our anthropologist�s (Hafferty�s) statement that: �Introspection and reflection are terminal diseases in medical school.� (7) The popular case-based curriculum which now dominates most medical schools in Canada is a much more merciful curriculum than the previous lecture-based model. But regardless of what curriculum you go through, there is still a never-ending and life-long scramble to learn medicine. We therefore must learn to prioritize, and prioritize we do, according to the values of our culture. Even simple observation of how the hierarchy functions can teach us the values of our culture.

17. Case 5: The Heirarchy 64 y.o. man, dicharged home after a triple bipass surgery Presents to Emergency room short of breath Medical student in ER takes history and physical Preceptor briefly stated suspicions of CHF and intent to consult cardiology Cardiology resident takes thorough history and physical Preceptor announces suspicion of pneumonia. Consults Infectious Disease ID resident spends good deal of time; repeats history and physical Preceptor suggests diagnosis is Dressler�s Syndrome, therefore, consults cardiac surgery Cardiac surgery resident takes history and physical Consider the case of a man, recovering from cardiac bypass surgery, brought back to the ER due to extreme shortness of breath. The medical student in the ER spent a good while getting a compassionate history and physical. Her preceptor zoomed in, briefly stated his suspicions of CHF, and his intent to consult cardiology. The cardiology resident came in, took a most thorough history and physical, then the attending came in, announcing that the patient did not have CHF, but likely had pneumonia, and his problems were all about infectious disease. So then the infectious disease resident came in, and kindly repeated the entire compassionate history and physical, got his preceptor, who briefly came in and said that the patient had no pneumonia, and in fact had Dressler�s syndrome, a rare complication of cardiac surgery. So, naturally, the thing to do would be to consult cardiac surgery. So then the cardiac surgery resident came in. Guess what she did� Other than futile repetition, what might an outsider notice? An outsider may observe that of the whole hierarchy, it is the medical student or resident who spends the most time with the patient. It is the least trained member of the hierarchy that usually ends up dealing with the complicated, time-consuming psycho-social issues of the patient, and it is most often the lowly medical students who find themselves in a position to comfort the patients. The medical student quickly perceives that these issues, apparently of too little importance to concern the more powerful members of their culture, should not take priority�Consider the case of a man, recovering from cardiac bypass surgery, brought back to the ER due to extreme shortness of breath. The medical student in the ER spent a good while getting a compassionate history and physical. Her preceptor zoomed in, briefly stated his suspicions of CHF, and his intent to consult cardiology. The cardiology resident came in, took a most thorough history and physical, then the attending came in, announcing that the patient did not have CHF, but likely had pneumonia, and his problems were all about infectious disease. So then the infectious disease resident came in, and kindly repeated the entire compassionate history and physical, got his preceptor, who briefly came in and said that the patient had no pneumonia, and in fact had Dressler�s syndrome, a rare complication of cardiac surgery. So, naturally, the thing to do would be to consult cardiac surgery. So then the cardiac surgery resident came in. Guess what she did� Other than futile repetition, what might an outsider notice? An outsider may observe that of the whole hierarchy, it is the medical student or resident who spends the most time with the patient. It is the least trained member of the hierarchy that usually ends up dealing with the complicated, time-consuming psycho-social issues of the patient, and it is most often the lowly medical students who find themselves in a position to comfort the patients. The medical student quickly perceives that these issues, apparently of too little importance to concern the more powerful members of their culture, should not take priority�

18. �We seem to prefer a cold or even disturbed physician with full command of current medical science to the most sensitive and compassionate bumbler.� - Dr. Melvin Konner And maybe the learner cannot help but feel what was stated by one medical student: [19: Konner]:�We seem to prefer a cold or even disturbed physician with full command of current medical science to the most sensitive and compassionate bumbler.� (6) However, it is encouraging that recent changes to the medical system are emphasizing that there is a danger in perceiving this as an either/or situation. Indeed, some learners & physicians are concerned that the pendulum may swing the other way� And maybe the learner cannot help but feel what was stated by one medical student: [19: Konner]:�We seem to prefer a cold or even disturbed physician with full command of current medical science to the most sensitive and compassionate bumbler.� (6) However, it is encouraging that recent changes to the medical system are emphasizing that there is a danger in perceiving this as an either/or situation. Indeed, some learners & physicians are concerned that the pendulum may swing the other way�

19. For instance, we always hear jokes about our residents and medical students FIFE�ing away (about the Feelings, Impact, Fears and Expectations of the patient). It�s come to the point where the learners are so inundated with the message, that they themselves start joking about it (e.g. during a code, a residents states: �but how does it feel to be dead?�) What are your impressions a preceptor? Are residents consistently using a patient centred approach? For instance, we always hear jokes about our residents and medical students FIFE�ing away (about the Feelings, Impact, Fears and Expectations of the patient). It�s come to the point where the learners are so inundated with the message, that they themselves start joking about it (e.g. during a code, a residents states: �but how does it feel to be dead?�) What are your impressions a preceptor? Are residents consistently using a patient centred approach?

20. Case 6: Role Modeling Difficult, complex history Poor eye contact, standing at foot of bed. Interview interrupted Preceptor response: �I�d be far more impressed if you made a real connection with this person, than if you got a perfect record of all her facts.� Here is one last case, which exemplifies the potential positive impact of role modeling. Two second year medical students were sent off to interview a patient with the task of gathering and presenting a complete history in � hr. The patient was tough to interview; she had a long and very complex medical history. She also had a very stiff neck, & was unable to lift her head to look at the students. So she spoke to the ceiling, as the students proceeded to unceremoniously interview her feet. Half-way through the interview, the preceptor took them aside, and asked how they thought the interview was going. They commented on how the history was so complex, that it was difficult to get their bearings. Again, he asked them what they thought was the problem. Again, they rambled on about disorganization disasters and difficulties with differential diagnosis. Once again, he asked them what they thought was wrong. What was wrong, in fact, was that they were not even trying to connect with this patient. He explained the frequent sacrifice of compassion for the �gathering of all the medical factoids� when time is pressed. When the students reminded him that they had a rather jumbled and very incomplete history to report in ten minutes, he replied: �I�d be far more impressed if you made a real connection with this person, than if you got a perfect record of all her facts.� Hopefully, this example shows a very simple and powerful way in which preceptors, aware of role modeling, can convey the attitudes needed to prevent the sad outcome of many physicians. Have any of you had any inspiring encounters, where you got a positive message about the values of our culture? What made this encounter so effective? Here is one last case, which exemplifies the potential positive impact of role modeling. Two second year medical students were sent off to interview a patient with the task of gathering and presenting a complete history in � hr. The patient was tough to interview; she had a long and very complex medical history. She also had a very stiff neck, & was unable to lift her head to look at the students. So she spoke to the ceiling, as the students proceeded to unceremoniously interview her feet. Half-way through the interview, the preceptor took them aside, and asked how they thought the interview was going. They commented on how the history was so complex, that it was difficult to get their bearings. Again, he asked them what they thought was the problem. Again, they rambled on about disorganization disasters and difficulties with differential diagnosis. Once again, he asked them what they thought was wrong. What was wrong, in fact, was that they were not even trying to connect with this patient. He explained the frequent sacrifice of compassion for the �gathering of all the medical factoids� when time is pressed. When the students reminded him that they had a rather jumbled and very incomplete history to report in ten minutes, he replied: �I�d be far more impressed if you made a real connection with this person, than if you got a perfect record of all her facts.� Hopefully, this example shows a very simple and powerful way in which preceptors, aware of role modeling, can convey the attitudes needed to prevent the sad outcome of many physicians. Have any of you had any inspiring encounters, where you got a positive message about the values of our culture? What made this encounter so effective?

21. �It seems to me I had a little vial of sweetness and kindness around stomach level. It�d been full when I was born; half of it had sloshed out in miscellaneous events since then, but I was hanging on for dear life to those remaining couple of ounces�Anyhow, serendipity had bailed me out on more than one occasion� Maybe serendipity would do it again and save that sloshing bit of enthusiasm and innocence. But when it�s all over, years from now, will I know?� So the bottom line is: role modeling is not only a powerful force in the enculturation of medical students, but it seems to be underestimated by both the student and the preceptor. Many of the lessons are given inadvertently by the teacher, and are adopted unconsciously, and very early on, by the student. The result can be wonderful � but if we are not careful, can be potentially quite harmful to both the patient and the future doctor. Docs have been described as: irritable, hypersensitive, over-confident, withdrawn, exclusive and distant.� (1) Studies show that these qualities not only apply to their professional life, but also spill into their personal lives. One student stated it like this: � So the bottom line is: role modeling is not only a powerful force in the enculturation of medical students, but it seems to be underestimated by both the student and the preceptor. Many of the lessons are given inadvertently by the teacher, and are adopted unconsciously, and very early on, by the student. The result can be wonderful � but if we are not careful, can be potentially quite harmful to both the patient and the future doctor. Docs have been described as: irritable, hypersensitive, over-confident, withdrawn, exclusive and distant.� (1) Studies show that these qualities not only apply to their professional life, but also spill into their personal lives. One student stated it like this: �

22. Good luck with your teaching. The next generation of doctors are watching you!

23. References Allan D. Peterkin, 1998. Staying Human During Residency Training, 2nd ed Jean-Charles Sourina, The Illustrated History of Medicine, Harold Starke Publishers Limited, London, 1992. Thomas Neville Bonner. Becoming a Physician - Medical Education in Britain, France, Germany, and United States, 1750 - 1945, Oxford University Press, MY, 1995. Montaigne, Essais, Extraits, Univers des Lettres Bordas, Bordas, Paris, 1985. Moliere. Oevres Compl�tes I, Garnier-Flammarion, Paris, 1964 Melvin Konner. Becoming a Doctor. Elisabeth Sifton Books, NY, 1987. Frederic W. Hafferty. Into the Valley, Yale University Press, NY, 1991 Attia, T. Personal Experience. 1997. Merriam-Webster Online. 2005. http://www.m-w.com/ Klass, P. A Not Entirely Benign Procedure: four years as a medical student. Penguin Books. 1987. Charles LeBaron. Gentle Vengeance, Richard Marek Publishers, NY, 1981. Author Unknown. March 19, 2007. Debated Studies: Animal labs for medical student. http://studentdoctor.net/blog/2007/03/19/debated-studies-animal-labs-for-medical-students. SDN . Hands-on Clinical Rotations in the United States for international MDs www.americlerkships.com. Attia, T. Personal Experience. 2004. Attia, T. Personal Experience 1999.

24. 24 Thank You This module was written as an aid to the Preceptors in the Postgraduate Family Practice Program at the University of BC. Study credit is available to groups of preceptors who complete the module Please give us your feedback on the module so that we may improve it for others. Email your comments to Dr. Fraser Norrie, Faculty Development, UBC Family Practice Fraser.norrie@vch.ca