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AAMC Panel releases Report on Bioterrorism Education Lawsuit Filed Against Princeton Review Containing SARS: University of Toronto Rises to the Challenge Nanotechnology: The Science of the Very Small Innovations in Medical Education: Doctor in the Court A Word from the President: Clinical Investigators for a Global Future Viewpoint: Summer School, NIH Style
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Containing SARS: University of Toronto Rises to the ChallengeSARS first appeared in the far southern Chinese province of Guangdong last November. This quiet beginning, of what would become a global concern, barely registered on the media's radar screen. But three short months later, when similar cases were reported in Vietnam - including the illness of an American businessman with an unknown form of pneumonia - the world started paying more attention. On March 12, the World Health Organization issued a global alert about a new infectious disease of unknown origin, and soon thereafter, the first SARS cases in Canada were identified.
Toronto, a city with a metropolitan area of more than four million, was the first North American city hit hard by the virus, likely imported by travellers from Asia. Rising to the challenge, public health agencies, hospitals, and healthcare educational institutions collaborated to contain the outbreak, and have so far restrained most of the cases to the area's hospitals, where quarantines are still in effect. After some early successes, in early June more than 5,000 people were quarantined in Ontario as authorities tried to control another potential outbreak. Twenty-nine people from the Toronto area have died from SARS, with 31 total throughout Canada, as of June 3. (See box.) According to a University of Toronto press release, public health agencies have not advised the alteration of university activities. Faculty, staff, students, and guests all have been urged to pay attention to the agencies' advisories and not to participate in public activities if they meet any of the criteria for self-quarantine. These criteria include having close personal contact with a SARS case, having a history of travel to countries with SARS in the past 10 days and the onset of symptoms, and having an order from public health agencies for specific groups or visitors to specific locations. Medical education disruptedPrior to this latest advisory, the university and its affiliated hospitals had to cancel medical education activities, in some cases affecting the timely completion of annual exams, residency programs, and continuing education courses in April. Although temporarily disrupted, educational programs were not substantially compromised, because faculty responded quickly by creating adaptive curricula and rescheduling exams and rotations. But SARS did affect the curriculum of third-year medical students. "One entire six-week rotation of the third year [of medical school] was essentially missed," says Rick Frecker, M.D., Ph.D., University of Toronto Faculty of Medicine associate dean for undergraduate medical education. "We struggled in the early weeks of the outbreak with offering it didactically, but it became increasingly harder to do that." Because of the strict control of the movement of hospital workers, it was especially difficult to get faculty who work at one of the local hospitals and were designated as "clean" of the virus to go teach at the university, according to Dr. Frecker. Faculty, residents, and other healthcare workers working in Toronto's hospitals were asked to refrain from going into other area hospitals to limit cross-hospital contamination. Faculty physicians were also asked to avoid meeting in groups where more than two hospitals were represented. "We did all our business by teleconference, and whenever we had to meet in groups with more than two hospitals represented we wore masks," Dr. Frecker continues. "So, it just wasn't feasible to bring in clinical tutors to teach our students, as a matter of course." Ultimately, university officials decided to suspend the April rotations and to offer them at the beginning of the fourth-year fall semester. "That six-week rotation will be offered again next fall as a third-year rotation with full exams and everything else," explains Dr. Frecker. Residency programs were also slightly disrupted as some rotations had to be postponed in the month of April, according to Toronto's Associate Dean for Post Graduate Medical Education Murray Urowitz, M.D. He sees no cause for concern, however. "We feel confident that we can fulfill the goals and objectives that were missed during that month," says Dr. Urowitz. "Program directors will make sure that over the five-year programs such deficiencies will be accommodated." Front-liners affectedLike other parts of the world with SARS outbreaks, most of those infected in Canada were healthcare workers. Some faculty and residents from the University of Toronto came down with the virus, although no deaths occurred among them. "Ongoing support for all healthcare trainees is important," says Dr. Urowitz. "This is a very frightening time for people, when they are put into situations where there's imminent danger for themselves. There were a number of trainees who were very distraught during this last outbreak, and it was important to have mechanisms whereby they could express their fears and be reassured or helped in many ways." According to Dr. Urowitz, "the vast majority" of residents accepted the risks of potential contact with highly infectious patients "as the role of any healthcare professional." Only a small minority of residents was substantially frightened and asked for help. Not surprisingly, faculty also were not immune from such fears. "Clinicians are facing something they have not faced before, except at the beginning of the HIV/AIDS outbreak," says David Davis, M.D., associate dean for continuing education. What is at stake now, according to Dr. Davis, is the faculty's "own kind of personal safety, our sense of security in the healthcare system and our role as mentors for students who are troubled about the SARS outbreak. I think there's a plea here for all of us to think about faculty development, and how important it is." Another thing the crisis brought to light was the need to start thinking about "different modes of communication" when trying to keep the disruption of educational programs as minimal as possible, Dr. Davis says. "That has got us thinking about and planning for more distance education technologies, like Web-based learning, Web-casting of CE [continuing education] activities, or Web-enabling them so that we can hold traditional courses and archive slides … for those who missed the courses." In addition to indicating what needed to be developed in the curricula and other aspects of educational programs, the crisis also showed university officials what they were already doing right. "Our public health curriculum is quite comprehensive in terms of community health, and we felt that this episode vindicated the depth in which we cover all of these materials," says Dr. Frecker. "Ultimately, we felt that the practical contact with the outbreak reemphasized for our students the real importance of some of the things they were being taught, and helped convert some of the theory we teach into very practical reality," he adds. Working together
University officials also realized that part of having an administrative structure capable of handling public health emergencies means having an established and transparent decision-making process, something the university already had pre-SARS. The Hospital University Education Committee, composed of the medical school's four associate deans, the affiliated hospitals' vice presidents for education, and the school's senior department chairs, was the means by which involved officials decided on matters such as rotations and programs' temporary cancellation. "We met by teleconference to discuss [our] decisions, so we had good coordination between the hospitals and the faculty because of this senior-level hospital and university educational committee," says Dr. Frecker. The primary feature in how the crisis-handling process worked, he adds, "was good communication, upfront sharing of information, and easy contact by e-mail and telephone with the key decision makers. The key was knowing who was in charge of what, how to reach them, and making sure that we met, typically by teleconference, whenever necessary." Effective communication between public health agencies, hospitals, and Toronto's population has helped to maximize the containment of the virus, adds Dr. Urowitz. He attributes this effective containment to public health agencies' quick response to the outbreak and the public's unprecedented cooperation. "The public health system kicked in very well," he says. "Even thought it was probably undermanned and undersupplied, agencies acted very quickly." Rules were developed and implemented quickly, and containment became the objective, he explains. And, to his surprise, everyone cooperated. "When they were asked to be quarantined, the vast majority of them comp- lied. It's astounding to me." Although the number of SARS cases in Canada has risen recently - in early June there were reports of a medical student who had worked in a maternity ward who later had SARS symptoms - had it not been for the public's cooperation and for public health agencies' and medical officials' calculated strategy, the numbers could have been much worse. Since the initial outbreak, hospitals have made an even stronger push on history taking, good hygiene, screening, and isolation procedures. Hospitals and public health authorities have cooperated in things such as wearing masks in appropriate conditions, controlling hospital entry, and creating screening questionnaires for all public events. Giving an example of the meticulous processes involved, Dr. Frecker spoke of his most recent trip to a local hospital. "I was identified at the door and had to tell them where in the hospital I was going," he begins. "They took a history of my recent contact [with SARS], and I was asked to wear a mask. I washed my hands with alcohol before I went to the clinic, and was signed off. When I went into the doctor's office, I was signed again so that the hospital had a trace on me wherever I went [so] in case anything had happened they would know exactly how to get me and where I had been." In Dr. Urowitz's opinion, however, the most impressive aspect of the crisis was not necessarily the careful and effective manner in which the involved institutions handled it; the individuals involved, he says, were the true stars. "We often cite the cliché that you go into health care because you are interested in service to the public," says Dr. Urowitz. "This really exemplified that concept. I think the nurses and the healthcare workers and all of the physicians working in the hospitals were amazing. They put themselves at risk and recognized that this is part of their job. If you ask me the main story that came out of all of this, that was it." - Suria Santana |
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