A Medical School Course With a Difference
by J. Pearpoint, M. Forest and Y. Talbot
J. Pearpoint -
Exec. Director, Centre for Integrated Education & Community
- Auxiliary Professor, McGill University
- former President of Frontier College
M. Forest -
Education Director, Centre for Integrated Education & Community
- Auxiliary Professor - McGill University
Y. Talbot -
Associate-Professor in Family and Community Medicine,
- Chief of Family Practice at the University of Toronto
Physicians meet clients with special
challenges and life styles in their daily practice. Vive la Difference,
a selective program offered at the University of Toronto to First
year medical students, aims at increasing student awareness of
their own attitudes toward their inner city clients. The paper
outlines the content and process of this teaching experience.
Vive la Difference
The streets are exploding. People are getting
hurt. There is poverty, racism, violence. Single parents, kids,
gangs, drugs, booze - families - all are part of the explosion
of life on the street - life in urban war zones.
Modern medicine - like most other institutions
- is ill equipped to deal with this new reality. But it is here.
There is no choice. Next week it will be more intense. Crack
babies and multiple addictions will haunt all our corridors.
"Vive la Difference" is an optional
course for a select group of 1st year medical students at the
University of Toronto to explore the implications of these issues.
It was developed by Dr. Yves Talbot, (Head of Family Medicine
at Mount Sinai Hospital in Toronto), Jack Pearpoint (then President
of Frontier College) and Dr. Marsha Forest, Founding Director
of the Centre for Integrated Education and Inclusion Press International.
It began late one night in 1985. The three
met to discuss how medical students could become more familiar
with the reality that they would be facing in cities - a reality
that was untouched by the vast majority of their course work.
Five years later, Vive la Difference recruitment is by word of
mouth - from previous students. The limit of 12 has always been
exceeded by students demands. A healthy sign.
The original course objectives:
To increase awareness of one's own values and attitudes toward
people with disabilities and to confront issues such as illiteracy
and different lifestyles.
The description explained:
Family physicians working in the community deal with patients
with various ailments and lifestyles. Because of this, the physicians'
values are constantly challenged. Being aware of one's own biases
and understanding the patients' needs are essential to the delivery
We specified that "Students participating
in this course should be prepared to come away with attitudes
that will never be the same."
Our original focus was on issues affecting
people labeled mentally retarded. However, in discussing how
to sensitize and expose students to these issues, we confronted
our own biases. Similar issues were faced by many "so called
deviant" populations. We decided to expose the students
to the broadest possible spectrum of life that they would encounter
in an inner city practice.
The time available was 10 two hour blocks
in the spring. We decided that following the first meeting at
the University, all other "encounters" should be closer
to the "home turf" of some of the people we wanted
students to meet.
Our focus was to "introduce"
the students to people - to sub cultures who will require medical
care, and who are at risk of being gravely misunderstood and
The list of "labels/issues" we
tried to expose people to included:
Chronically mentally ill
Gay, Lesbian and Aids
Addiction Problems - drugs and alcohol
Many of the people overlapped several categories
- but the pattern is clear.
The Structure was experiential. We wanted
to affect attitude - and our assumption was that to cut through
to raw attitude,the approach had to be experiential. But experiences
in isolation have minimal impact. Thus, we designed each unit
to include time for:
The presentation was "real life,"
by real people on their own turf, about issues those people considered
important in their experiences with the medical system. We encouraged
question and answer time - pushing people to ask the questions
they were afraid/embarrassed to ask.
We followed this with our "processing"
time. We withdrew as a group to discuss the presentation without
the guests present. This processing tended to have two components.
Firstly, the students talked to each other about their reactions
- their values - their beliefs. Again and again, the students
reflected that this was the only opportunity they had to actually
get to "know" their fellow students. They worked long
hours together, but seldom did they ever actually get to "know"
how another student thought. Informally, the faculty would join
in and guide the discussion to a second stage. Invariably, students
would make remarks like, "It would never happen like that...",
at which point, it was absolutely essential for the physician
(Yves) to report that these things happen - in the emergency
ward, etc - and thus introduce "reality". Similarly,
Marsha and Jack added lateral examples, so that it did not become
simply a "show", but rather a sampling of broader more
complex societal issues.
A SAMPLE COURSE
An afternoon with Judith Snow - in her
apartment. Judith became part of our core faculty. Judith is
an amazing woman, and one of the leading authorities on the continent
on deinstitutionalization and building support systems for people.
But on first encounter, the students only saw a "quad four"
- not a person - but a diagnosis of profound disability. In fact,
Judith has no controlled movement except in her face and 1/4
inch in her right thumb - which is how she drives her wheelchair.
She types 35 words a minute on her computer using a "sip
and puff" attachment. She travels the world lecturing. But
like almost all of us, on first encounter, the students could
only see a wheelchair - and disability.
A student's written journal recorded
"The first thing I noticed about Judith
was her wheelchair. My feelings were mixed. I felt sorry for
her. I felt curious about her and I couldn't understand how she
could possibly live outside an institution.
After the session, and after leaving Judith's
apartment, I felt mad both at the community at large, and at
myself for knowing so little and having such preconceived notions.
I started questioning everything as I never had before. What
was my role as a doctor anyway?"
The whole situation was traumatic for these
young medical students. Judith is one of the most physically
disabled persons in Canada - and she lives independently - in
her own apartment - with her own attendant care system. She works
- full time - and travels internationally. All our predispositions
suggest that Judith should be dead - and if living - on a nursing
ward. And then she lectures. She tells her own story of medical
experimentation that lost the use of her arms; of being malnourished
almost to death in a geriatric hospital, the only place for her
after finishing her Masters Degree in Counseling. We always arrange
the room so that people naturally have to help Judith with snacks,
and help her drink her tea. No one ever thinks about "the
handicapped" quite the same after spending an afternoon
with Judith. Part of the power of time with Judith is her amazing
capacity to include people. She is not alone.
This gives the flavour of the course. Week
after week, punctuated with regular "rest stops" for
reflection and always - treats from a bakery, we led each new
SELECTION OF CO-FACULTY
The range of communities we introduced
people to varied - slightly. The list of topics was easy to generate.
The presenters were a more delicate selection. Some have become
"regulars". Others we dropped after a try-out. The
selection criteria to be co-faculty were:
a personal interaction with the medical
system in the past.
being in control of the frustration/anger from that experience
an acceptance that the "students" had done nothing
a willingness to contribute to medical training
a willingness to tell their own story publicly
a capacity to articulate their experience to a group without
We learned a great deal in selecting co-faculty.
Initially, we were worried that we would have trouble finding
individuals and/or groups to teach about their various communities.
We were wrong. We are lobbied constantly by various people to
add them/their issue into the course. A more delicate problem
was the issue of hostility to the medical profession which is
substantial in many communities on the street. It was healthy
for the students to see "hostility" - but not too much.
The individuals had to be controlled enough to "explain"
their feelings - not just explode at "doctors."
THE STREETS & ILLITERACY
As the weeks passed, different street communities
told their story. Each year, we toured Beat the Street - and
went on a guided "street walk" led by young people
- who live on the street - or in nightly hostels. Our guides
were young kids - troubled, articulate, yearning for a future.
They were also pimps and prostitutes and addicts. To survive,
many were involved in crime. Aids was part of their reality.
Violence was everywhere. But at Beat the Street, these kids were
students and tutors - teaching each other to read and write.
Almost all had been scathed by school, but their formal skills
were limited. As the constantly changing cast on the street told
their stories, our students heard about abuse, neglect, rape,
abandonment. They heard kids tell how their "community"
on the street was their "family" - they had friends.
None glorified the street, but few were ready to "go home".
That was even more dangerous. Most wanted a way out - but they
didn't know where to begin.
"I definitely live in a sheltered
world. Today we met the people at Beat the Street. It was the
first time I had ever seen a hooker or met a street person. I
found out "they" were people - not stereotypes. I'll
be a more sensitive doctor as I'm starting to question my own
narrow world and open it up."
- a student
These two sessions - at the beginning of
the course usually took a whole day to "process." The
experience was so staggering to most that it challenged their
values - their beliefs - assumptions they had made about systems,
people, and medicine. Invariably, "horror stories"
of neglect and mistreatment arose. These were hard for students
to hear. It was a painful listening, and they needed to talk
out their feelings and the information.
And so the course continued. Another "constant"
was a presentation from "People First" - an association
of people labeled mentally handicapped. Peter Park and Pat Worth,
Presidents of associations in Ontario always left people in stunned
silence. Peter spent 17 years locked up on a back ward. He is
now married and working full time. Pat spent almost as many years
in institutions after being abandoned by his family. He jumped
through a window to escape - and now heads the provincial association.
Their stories shatter student confidence in "institutional
support." People cannot believe that they were "labeled"
mentally retarded. One student commented that Pat's lecture was
perhaps the most brilliant he had ever heard - and he specifically
compared Pat to his university lecturers.
This is where the role of the faculty becomes
critical. Independent of what has actually been said, some students
begin to get very defensive. They rally to protect "medicine"
and social values. They don't want to believe what they are hearing,
but they have no alternative. Debates ensue. They want to rationalize
that every guest is a "special case". They want us
to tell them that what they have heard about is not real - that
it is an aberration - a quirky exception. The role of the physician
here is vital. Someone in authority has to say to the students,
"They are telling the truth. ... This happens all the time...
I have made decisions that were mistakes - like what happened
to these people." And in the same breathe, it is essential
not to idolize the presenters. Street people can and will also
be miserable, abusive, violent, etc. The picture is far from
all "sweetness and light". But, on Saturday night when
a beaten up, single mum arrives in emergency smelling of booze
and filth, it is absolutely essential to remember that she is
a person and deserves to be treated like a decent human being.
It will be hard, but if you remember that every person has another
side. The patient is BOTH a loving mother, and a woman who has
hit hard times and the bottle to deal with her agony. It will
be easier to listen for relevant symptoms - which may well be
more complicated than a hangover, if students remember...
One of the messages that came from almost
every community was their shared terror of the medical system.
They begged, without exception, to be treated like people - and
to be preserved from arbitrary abuse and mechanical treatment.
They wanted to be well, to see doctors, but preferably on their
DIFFERENT SEXUAL PREFERENCES
Our afternoon with gay and lesbian families
was shattering without exception. Most of the students "knew
about gays" from television or a walk on Yonge street on
Saturday night. They had no knowledge of "families"
- but most important - they thought they did. Our meeting was
at a very middle class apartment. Four co-faculty talked. Two
men and two women - both of whom are raising families. Preliminary
discomfort dissipated quickly as the students discovered that
Neil and Dale were extraordinarily competent and caring professionals
- who loved each other very much. They were a stable couple -
in a society with very little family stability. They had teenage
sons who were "straight" but comfortable with their
"parents". The details varied from year to year, but
the session was about shattering myths. No one denied that there
were flamboyant gays - much like there are super macho men. But
we all learned that one must not operate on grossly inadequate
stereotypes. And the pain of rejection by many doctors - when
people are genuinely ill was a story that the students did not
want to hear - but they listened.
PEOPLE IN PRISONS
All of us have strong opinions about the
people we label criminals. But, most of us will only see these
people through the glare of television. We seldom encounter the
real people. Doctors are more likely to meet all types. The urban
street scene includes extensive crime - gangs, violence. One
of our sessions on alternate years was to spend a block of time
with a individuals who had spent their lives - largely in jail.
These sessions were fascinating in that they forced the students
to think about - and articulate another packet of largely unexamined
beliefs. Spending a block of time with a man who has been convicted
of murder - and is unrepentant is sobering. But it was particularly
disturbing because most of the people we met were charming. They
were "sales people" and could sell you a bill of goods
- any bill of goods. And as gentle and pleasant as they were
with our students, clearly there was another side - of danger,
violence and the excitement of all that. Fortunately, by choosing
carefully, our co-faculty didn't spend all their time telling
entertaining stories. A lifer left the students with a homework
assignment. "If you want to know what its like in prison,
go home, take the door off your bathroom, move the television
in if you want, but stay there - just for a long weekend. And
remember, no door, no leaving." We never checked to see
if any of the students actually locked themselves in, but the
example conveyed meaning. Gradually, the students came to understand
the meaning of "institutionalization" and the profound
impact it has on people.
DINNER WITH FELICIA & MARIA
The closing session of the course was always
very special. Our food theme moved into high gear as we had a
dinner with a family - like the Galatis - in their home. Rose
and Dom Galati are teachers. Their two beautiful teenage daughters,
Felicia & Maria are both medically fragile and labeled profoundly
mentally and physically handicapped. They live at home with their
parents and go to regular schools. That is what is special. The
historical pattern would have been (and was for Maria) "life"
in a series of care giving institutions. But Rose and Dom loved
their children and wanted them to experience all of life they
could. They fought and worked and have integrated their children
back into their community - their church, their neighborhood.
The children have friends. This seems so simple, but it has been
a massive battle. It involved changing the basic belief systems
of school boards, and others - to see that Felicia and Maria
are human beings. They too have contributions to make, and the
right to be full citizens.
As people sat over dinner, feeding Felicia
and Maria, and feeling the warmth of a healthy Italian family,
the discussion about the power of physicians to sign children
into institutions for life took on a crystal clarity. The impact
deepened as each person gradually realized that all of us age
and become "imperfect" and thus could become victims
of a medical sentence to "institutionalization. Rose talked
about the pain of the well intended remarks of physicians as
they informed her that her second new born would also be a "vegetable."
Good intentions don't make up for the months of grief that ensue
from that kind of remark. The discussion always returns to people
- recalling individuals they have met - people new to their consciousness.
The students recall Norman Kunc, born with
cerebral palsy. Doctor's told Norman's mother to let him die
- or to put him away. Today, Norman still has cerebral palsy.
Medicine cannot fix that. But he was a gold medal winner at York
University. He is a practicing family counselor, and of all things,
an internationally renowned speaker. People with cerebral palsy
aren't supposed to be "speakers." Organizations pay
to have Norman speak. He is also an expert sailor (solo racing)
and a master chess player. It would have been so much better
if the physicians had been brutally frank with Norman's mother
and said, "We think your child has cerebral palsy. We simply
do not know what that means in terms of his potential, but take
your child home and love him." Our concept of "normality"
needs to be broadened - and more inclusive.
Rose and Dom give the same message over
dinner. It is hard to eat at someone's table and not remember
that they are people first - not just "cases".
There are many hard discussions in Vive
la Difference. Two of the issues that are constant are "deinstitutionalization"
and "power". A sub theme for almost all the co-faculty
- regardless of their community is the destructive power of institutional
containment - and the counter-veiling need to be recognized as
a person - a whole person. It remains a delicate balance to understand
and remember that when you are medically sick, a hospital (institution)
is a very helpful and important asset. But, the profound impact
of the institutional reality can be so intimidating and upsetting
to many people - and almost all of the people we encounter, that
to have a positive net impact, those institutional encounters
must be minimized.
The second issue that is a struggle for
student doctors was a surprise to us. The issue is power. On
average, the students did not want to accept the reality that
they would be very powerful people. They wanted to be thought
of as "nice and caring". They wanted to avoid the fact
that doctors are powerful in our society. A doctor's signature
can commit a person to treatment - to surgery - to procedures
that can save a life. But the fact is that a doctor has power
of life and death over many patients - at the very time when
we are most vulnerable. Coming to terms with that power and influence,
and still remaining sensitive and caring was an issue that students
The evaluations on this course are fascinating.
The most negative comment is actually a positive. Students complain
that this is not available to all students. "It should be
compulsory." On their own initiative, classes have written
to the Dean and proposed it. Students write about the fact that
they have been forced to think about issues they never thought
about - and to come to terms with their own values. Almost to
a person, they say they will never be the same. The rate it as
one of their best classes ever.
The fact that the students from previous
years recruit students from the new crop says a great deal. We
have another informal measure. Our course has recently been on
Tuesdays. On Wednesdays, there is a formal gathering of all the
1st year students. The Wednesday gossip has been, "What
did Vive la Difference do yesterday?" The word is getting
out. Some students even organized extra additional sessions with
some of our speakers - for their fellow students - evenings.
That is a very clear evaluation message.
We attribute our success to the excellence
of our co-faculty - who have been hurt badly, but have turned
the hurt into helping. They want to produce a generation of professionals
who won't make the same mistakes that caused such agony in their
lives. But, their energy was to build a partnership of trust
- and to support the caring competence of these students - who
desperately want to be caring and competent.
Students are required to write a page after
each session on the impact of the session on their own life.
The authors are currently reviewing 5 years of this data through
We hit a chord. We assume that these students
want to be good doctors. We appeal to their best instincts. We
give them an opportunity to examine their own values, and to
meet co-faculty who can genuinely help them to be better professionals.
To practice good medicine in the inner city of the 90's, you
need to understand the enormous variety of communities that will
cross thresholds. Vive la Difference gives students and introduction
to those realities - and skills and knowledge that allows them
to go further if and when they are ready.
The last words go to the students:
"This course has been a fantastic learning experience. It
has taught me that although I thought I was open minded, I wasn't.
This is the first course I've taken that encouraged me to participate
and discuss my values. Everyone should have to take this course."
- a student
"Vive la Difference" certainly
worked! you took a naive young group of medical students and
actually made them think about themselves and issues they will
be facing every day in the future."
- a student
"I have not had to think about my
values, dreams, etc. I was too busy studying for medical school
and getting A's. "
- a student
"I won't simply accept things now
like the need to put people in institutions, segregated schools,
etc. I want to learn more, think more and I know I'll be a better
doctor because of this course."
- a student