Interview with Sev Perelman
About the peculiarities and trends in the modern medical education, profession of medical doctor and medical educator, sources of inspiration in routine practice we talk to Sev Perelman, medical doctor (MD, MSc, CCFP(EM), FCFP(C), CHSE-A, CIPS), associated professor of the University of Toronto (Canada), director of the simulation training center in the Mount Sinai Hospital.
- Why have you decided to become a medical doctor and medical educator? What would you have done differently?
It’s a very complicated question that alone can take a very long time of discussion, because the older I get, the more reflection I have on the deep-seated reasons of my career. In my family there are no medical professionals. But I believe that my choice stems from an interest in biology and a human body combined with the desire to help people, some sort of intrinsic hypersensitivity towards my own pain and other people’s pain. So, the aspiration to be a physician formed very early in my life. And then I was in the Junior Academy of Sciences in Lviv. There I was placed at the laboratory of biophysics of the cell named after Paladin. There you feel being a part of the exclusive club of keeners, or even nerds if you like. It was a very interesting environment, and we grew within it and got recognition for our scientific achievements. I guess, the membership in the Academy resulted in strengthening my interest to pursue in medicine. Then I was fortunate to gain acceptance at the Saratov Medical University and studied there. After I immigrated to Canada, I got accepted into the master’s program in the Department of Physiology. And only then I became a part of the Toronto University Medical School.
I think I’m one of the very few people who managed to experience both the former Soviet medical education and so-called Western medical education. And this alone may be a topic for discussion because it’s fascinating even now, 20 plus years later, to reflect on that and the difference in approaches.
In Canada while you study in a medical school, you don’t have a specific root to become a medical educator. But you are exposed to people who inspire you, who become your mentors, whether formally or informally. And medical education becomes a part of your day-to-day life. You can very clearly see and feel the difference good educator makes on you as the young physician versus kind of mediocre education. So that also became very interesting to me, and I was fascinated by the idea of passing the knowledge on. The interesting part is that to be a medical educator in the Western environment usually means that you have a substantial cut in your wages. On average academic physician makes about 30% less than some physician who works in practice outside the university. If you ascend the ladder of the medical educator, so you start as the instructor at the department, then you become a clinical instructor. Then you become a lecturer and then you can enter the three professors’ levels: junior professor, associate professor, and a full professor. None of this has an associated salary, believe it or not, so all your money you make as a clinician. So, we have not so much financial motivators to work in medical education. Among the motivators are ability to attain some sort of mastery level, feeling that you are impactful, and also feeling that you belong to a community that nobody else belongs to.
I never actually had a career in my mind when I graduated from the medical school. I just wanted to be a good clinician. But I got hired at the Department of Emergency Medicine at North York General Hospital, which was an academically affiliated center. And inevitably I was exposed to students and residents and fellows. I liked it, so I pursued it. But I never ever had a career in mind that I want to be a professor.
- Are there any programs to train medical educators in Canada?
For many, many years the concept of medical education was the following. If you are a physician and if you are a very successful researcher, then you get academic appointment and that automatically grants you access to students. So, the idea of professional medical educator didn’t exist, probably up until the late 90s. Nowadays if you have completed your clinical education and you get certification to practice, and you want to be hired, you have three areas that the university can offer you. Either you are a clinician-scientist and that requires a Master’s or PhD degree in science. Or you can be hired as a clinician-administrator – chair of a department, chair of a committee, dean. Or you can be hired as a clinician-educator. This is a new concept which started in 90s. And usually, you have to have Master’s or PhD in education. If someone really wants to be an educator and demonstrated excellence in teaching otherwise, and people want to hire him or her, university also offers programs. For instance, at the Saint Michaels Hospital, you can have a clinician-educator program, which is a one-year program. It does not lead to a Master’s degree, but it will lead to a certificate of a medical educator.
So, nowadays if you want to be hired as a medical educator at the University of Toronto, you have to have advanced training in medical education specifically. And that made a huge difference in how people positioned themselves and the quality of education geometrically has increased and improved. And as a flip side of that, the university started to recognize that educators are very valued, important part of the university community. Nowadays you can be even promoted just as an educator. You have to show competency in five domains and excellence in one. The domains are clinical work, medical education, creative professional activities, administrative work, and research.
Another interesting thing is that the part of your promotion as an educator is feedback of students. Any lecture, any seminar, any course somebody runs, students are required – almost obliged – to provide constructive feedback. This feedback is anonymous, and it’s very, very valuable. And you have to adjust your practice or reflect on what you’re doing. Especially now with very important emphasis on cultural differences, LGBTQ, black life matters and all those issues you have to acknowledge and become aware of your own biases and that they are reflected very clearly in all the relations with students. So, without good student relations, you can forget about promotion and you, in fact, can lose your appointment quite easily.
- Can you tell us more about the students’ feedback system, how you motivate or teach students to provide constructive criticism instead of simply complaining?
Let me explain to you, who are these students in the Canadian Medical University. So, in the entire country we have 500 spots in medical schools. In the University of Toronto class are around 240 students. The McMaster University has 70 students. That’s per year per class. In order to gain acceptance in medical school, you have to consistently demonstrate excellence since high school. More than 50% of people who enter the first year of medical school have graduate degrees, but the requirement is to have at least three years of university before you can even apply for medical school. The average age of those who enter medical school is about 24 years. So, we are talking about maybe 3-4% of top students in the country applying for medical university. And then you also have to demonstrate community activities, extracurricular activities. In my class I had two Olympic champions, the colonel of the army, the vice-president of the Bank of Alberta at the age of 33 entering medical school, and one of my classmates was the first violin of the Toronto orchestra. So, we have a very, very exclusive class, very mature people who demonstrated tremendous sustainable effort their entire life, volunteering jobs, traveling, and working refugee camps. The level of people who are in medical class is incredible. So, the issues that I often hear when I teach in some other countries related to students’ motivation is not applicable here at all.
Usually, a student can come up to see you and say ‘I felt that you weren’t prepared enough for the class or the level of complexity of this problem was not good, or the seminar was too boring’. Students will say it clearly and they can actually say interesting things. Every time I work with students, then I’m sitting and reading their feedback. And even being an educator with 25 years of experience, not unfrequently I pause, I think and adapt, and change.
I understand that there are different contexts. And there may be fear that students may overinflate negative remarks if they feel that they were not treated fairly. But as we don’t have marks anymore, only a passfail system, this fear is irrelevant. It became a very sophisticated system where you always feel that you’re being watched, but strangely enough, in a positive way. If you, let’s say, get negative feedback as an educator and there is a consistent pattern of this feedback. People will call you and will try to help you, provide solutions and offer supervision. I think it’s remarkable to witness that you start to develop trust in a system that it’s not designed to punish you. It’s designed to help you because you are a valuable person of the community, you invested a lot of time in learning to become an educator. The prevailing modus operandum of an educator is creating alliances and collaborations. It’s impossible to lift by yourself. I can’t even recall the time that I thought I designed a perfect simulation scenario, but someone looked at it and found ten mistakes and suggestions and it has always been changed. So that’s why we have a system of peer review. So, whatever you create, if it affects the learning of another individual, group of individuals, group of students, it’s always reviewed. Well, sometimes it’s not reviewed, but very quickly after the first course, you get enough feedback to realize ‘I should have reviewed it’.
- What are the key differences in your experience with medical education from the position of a student and from the position of MD, educator?
When I went through the medical school in Toronto, we had very few lectures. A lot of education was selfdirected learning. We worked as a group, and we couldn’t change the group. So, we embraced the idea of problem-based learning, which was really difficult to implement.
Now I think students are much more empowered to make a difference in what they perceive education is. It’s mind-boggling to see how much change in terms of the means for medical education happened. A lot of learning, especially during the COVID-19 year, became online, Zoom-based learning and virtual reality. Before the simulation training didn’t exist at all. I with my colleagues was the first one to establish the longitudinal curriculum in simulation in emergency medicine in 2009.
In terms of the consumer of education, the respect that you as a student feel from the professor is different. It sounds very foreign, but when I was applying to the medical school in Toronto I went to the office of admission as I wanted to ask some questions. The secretary turned to me and said: ‘Would you like to go to see the Dean?’. And in a second the door opened and Professor Bailey, twometer-tall cardiac surgeon, the Dean of Admission invited me to his office. It shows the respect that students have in a way that the relationships are very different. Professors are respectful, they’re approachable. The whole idea in modern medical education is that you want to flatten the hierarchy. You want to pursue the notion that all of us are learners. The difference between me and a student now is that I have an expertise helping a student to navigate through this amazing field of knowledge.
- Describe your professional routine now. What does it consist of?
I work in the Department of Emergency Medicine in a sizable hospital, one of the five academic bases for the University of Toronto Medical School. The emergency department treats about 50 to 60,000 patients per year. Each day we have seven overlapping shifts, 8 to 10 hours long. We have 32 physicians working in the department, all of them, of course, have to be appointed at a different level at the university. And we have about 180 to 200 nurses. When I come to my shift, I transition through my shift from resuscitation room to monitor rooms, to less acute and end my shift with patients with trauma. With me usually there is a student or a resident or a fellow – three different levels of trainees. In my case, I work now only twice a week.
The rest I have a full day dedicated to work in the simulation centre. Initially I was the one who was designing the programs, teaching and collecting all the feedback. Now, as we have more instructors, I personally don’t teach much at all – probably four or five courses through the year. But I make decisions about budgets and speak to donors to solicit some money to buy equipment. I teach internationally and enjoy an opportunity to have some impact on educators. I’m also the medical director for ACLS and BLS training, so I have to oversee the roster of instructors in that area. I collaborate in some research projects. I also work clinically three days a week in the clinic where do interventional pain management, ultrasound-guided injections etc. I serve as the medical director of education at the World Academy of Pain Ultrasonography United. I sit on a couple of university committees. And I’m also a physician for the NBA team in Toronto. When the team is playing, I have to be at the games.
So, I probably work about 60 hours a week on average, and strictly speaking, education per se, I would say, take maybe half a day to a day or up to 20 hours if to add mentorship in emergency department.
- What are the most important lessons learned from this variety of professional experience you have?
The most important lesson is that I should not be doing that many things. I think I should be more focused on one area, because whenever I become more focused, I achieve better results. So, this is the lesson that I would tell somebody who would start a career. Find the niche, pursue it. And also think of it as a tree. While you have your eyes on the trunk, how it grows to the sky, pay attention to the branches and whenever you can – collaborate. The best successes of my life happen from unexpected collaborations with people I never thought I would collaborate. My advice is set a clear goal and then use a radar to see what is around for collaboration.
- In your opinion, how responsibilities should be shared between the state and universities in the area of ‘producing’ competent health care professionals?
How the system works here. The Minister of Health says to the universities: ‘We have to produce physicians’. And the responsibility for the quality of education, the quality of produced physicians is on the independent colleges – not staterun but independent self-governing structures (like the College of Physicians and Surgeons of Ontario, the Royal College of Physicians of Canada etc.). It means the whole bunch of physicians got together and decide which competences graduates should have to be certified as a doctor. Twothree years ago the Royal College of Physicians of Canada had a committee which decided to switch from timebased medical education system to competency-based. We recognize and acknowledge that different people learn at a different speed. So instead of telling a student: you have five years to become a competent cardiologist, we are saying: these competences you need to become a competent cardiologist. We put these competences in a portfolio, and it is a student’s job to acquire those competences. We create opportunities for a student to learn the competences and to demonstrate them. Once you get the checkmark, you move on. You can spend four years in training or 10 years. It’s up to you. But the important thing here is that colleges are not government-run. It’s a self-censored, self-controlled, self-monitored institutions run by physicians with one mandate only. And this mandate is protecting the public.
It’s not the government that gives a license to practice. It’s the college of peers that gives a license to practice. Similarly, the colleges say to universities: ‘We don’t care how you teach. But these are the competences that we’re going to test’. The role of colleges to design exams: multiplechoice, observed physical state etc. The term that people use is a selfregulated profession.
And also universities got together and said: ‘We want to make sure we don’t screw up. It’s big money. It’s a big investment”. So, they created accreditation bodies. American College of Medical Education is an independent from government accreditation body that looks at universities. If the university satisfies accreditation criteria, it is accredited. But the government doesn’t care if the university is accredited or not. So, there are no borders between state and universities because they live in different plates. The government can allocate budgets to train physicians and can pay universities, so they are able to provide scholarships for students or reduce tuition rate, but even in this case the government doesn’t control the teaching process in the universities.
- And which role does simulation learning play today in medical education?
I have witnessed the evolution of simulation being integrated into medical education, so I can tell you the initial excitement: Oh my God, we have a doll, let’s play with it, let’s cut it etc. And everybody was saying all simulations are amazing. But now we know what works, what doesn’t work. So, fortunately, the simulation stops being an exclusive, amazing tool. It’s just a part of the toolbox. Now we are much more strategic about it. We have enough solid educational theories and research to show that you don’t need to use simulation to take first year medical students and teach them how the heart beats. The simulation really becomes much more precise in what we’re trying to achieve.
It also became mandatory because the conceptual paradigm of allowing people to learn on patients is over. There were times, when I was a student, that we could be asked to do some manipulation with a patient only after theoretical part of the course or after just reading a book. And now everybody who has access to patients, has to demonstrate the skills and pass through a stage of simulation training.
So basically, medical education can’t exist nowadays without simulation training. And other things are coming now – virtual reality and artificial intelligence is starting to play some role. But for sure without simulation, you can’t really do a task training. And also, simulation is crucial for a team training, including aspects of establishing a team, taking a leading role in the situation etc.
- Can you tell us more about the functioning of your simulation center?
The simulation center I am running is a hospital-based simulation center. Our medical students come to the hospitals from the first year of the medical school. So, they come to the clinical environment very early, and they start to see patients. And it makes sense while they are in clinical environment to go to the simulation center to get trained in whatever they need to be trained in this specific moment. And additionally, hospital simulation centers have the mandate to improve quality of care in the institution. So that’s where we have real nurses, real physicians, real social workers come and practice simulation.
The advantage of having simulation center in the hospital is that we train interdisciplinary teams. If I grab all the medical students and we’re going to train a response to cardiac arrest – in real life it doesn’t happen. You have nurses, you have other staff positions, like anesthesia. And we train the whole team together. That’s why a lot of our courses are interdisciplinary, and very few are monodisciplinary.
We also support trainings for police officers and firefighters. For them it’s mandatory to have an annual BLS (basic life support) training. So, we organize this activity. For example, recently we participated in a citywide emergency response exercise where we contributed with simulation training. It was a massive event: 5000 police officers, firefighters, army etc. I think it’s reasonable to involve other professions who require simulations.
For instance, in our center, we also had a couple of courses where we trained teams of gastroenterologists and social nurses who work in the community doing colonoscopies. It is worth mentioning that in the center where I work, I have to generate courses to generate funding to support the activity of the center. It’s non-profit but it’s for profit to cover the expenses anyway. I struggle with this a bit, and that’s one of the things I have to solve the next couple of years for sure.
- How do you assess the success of simulation training at your center?
This is probably the most difficult part. The metrics of success are very challenging. At the end the ultimate measure of success is to see whether simulation education and training resulted in better patient outcomes. Well, there’s a gap between the simulation exercise and the time point when you can see the success of a patient. I published with a couple of medical students the review last year in the British Medical Journal, where we looked at the evidence that the simulation training at the workplace resulted in improved patient’s outcomes. And there is undoubtedly evidence about that.
In terms of satisfaction with the process of simulation training, everybody likes it. Everybody feels safe, everybody feels nice playing with mannequins.
But when we are talking about a specific simulation centre, it is tough. We can look at the revenue – did we generate enough funds to pay employees for this year, so we can train all the interested people. We can look at complaints from the learners, analyze opportunities for the research generated for the simulation center. I think the metric of success has to be an overall organizational belief that it is important. And we can look at the occupancy rate, learning satisfaction, the buy-in by the clinical teams to do this.
- And from your experience, what is the most exciting aspects of being a trainer and the trainee in the simulation center?
Well, the most exciting thing is to see that whatever you do results in people improving their skills and competences. It’s such a privilege to see that people do something because of you. How the trainees can become in front of your eyes very competent communicators and decision makers, and diagnosticians and interventionalists. This is just incredible. And for me it is also such a pride and happiness to see the development of our simulation center. When I started, we just had one simulator in a room. And because of our team effort it grew into a very impactful simulation center.
And I and my peers are also fortunate to have a chance to teach abroad, in many universities. That’s just an incredible experience. I had the privilege of teaching the very talented medical educators in Ukraine just recently. And I want people to feel that if they aspire to do something, they can. If at the beginning of your career, what was driving you, was a desire to share knowledge, and you felt the possibility to change a complex subject into a simple one to help somebody to learn – don’t forget this feeling. There is nothing more rewarding than seeing somebody improving and growing. If your students do well, you should be very happy. And if your patients recovery well, you should be very happy. And all of this is uniquely encompassed by being a clinician and an educator.
- Do you have some recommendations for medical educators, for medical professionals, what they should read or watch?
To watch – the movie Patch Adams with Robin Williams. I think it’s a very interesting philosophical movie. In general, how people should approach life and being a physician, and how they should not take themselves too seriously because they know they’re not gods.
In terms of medical education resource there’s the whole concept of Free Open Access medical education platform. It’s FOAM medical education. If you Google FOАM medical education, you can find like anything there, on any subject. It’s put together by incredible group of people. It’s an open community where medical educators share their knowledge in a lot of things. It started in 2012, actually in a pub in Dublin.
And the other thing I want to pass to my colleagues in Ukraine and abroad. Rely on and demand peer review. Talk to your peers. Talk to stakeholders. Learners must have a say in what they need, what they want to learn, and how they want to learn. So, if you think that being adult age and having massive experience and worldwide recognition or whatever you call it, if you think for a second that I am confident that when I design a course or a lecture that I can guarantee that it is going to be the best absolutely – not likely. Unless you go through the educational needs assessment and talk to people what they want to learn, how they want to learn, you run a very significant risk of bringing your biases into the picture. Unless you get into a habit of doing peer reviews, you’re missing a chance of really excelling in what you’re doing, how you are doing. The idea of peer review, peer support, and collaboration with both, peers and also learners, should be an absolute necessary component to any educational activity.