Resident excited to continue U of T training while focusing on quality improvement and patient safety
Growing up, Dr. Carolyn Tan defined her ideal career as one that would align with her interests and strengths, be a good fit for her personality, and, most importantly, make every day – both the challenges and successes – feel worthwhile. She considered pursuing several jobs including math teacher, actuary and personal trainer before deciding on medicine.
In her internal medicine application in 2017, Dr. Tan wrote: “Internal medicine provides an exciting stream of new problems to solve. Even when patients have similar presenting [concerns], their comorbidities, social situations and individual personalities add layers of complexity.”
These words continue to capture what she loves about her work. She has found these opportunities to be particularly rich while caring for older adults, which inspired her to later pursue a career in Geriatric Medicine.
Dr. Tan has several reasons for why she chose to complete her internal medicine residency at the University of Toronto (U of T). First, she had an incredible elective experience on the Clinical Teaching Unit at Sunnybrook Health Sciences Centre, which also influenced her decision to select Sunnybrook as her base site. Additionally, she wanted to prioritize quality improvement (QI) research and teaching – areas where U of T consistently excels. After speaking with several U of T residents and alumni, she was confident the school would be the best fit for her both academically and personally.
“Toronto is also my home and I was eager to return to my family, friends and the city,” she says. “The home-cooked meals during my visits with family were a welcomed benefit. I’ve been known to joke that the bravest thing I’ve ever done is eat my own cooking.”
Dr. Tan was the Chief Medical Resident (CMR) at Sunnybrook during the 2021-22 academic year. Among the many CMR responsibilities, her primary focus was supporting the residents, especially given the additional challenges posed by the first two waves of the COVID-19 Omicron variant. Three years later, she continues to enjoy running into residents and medical students she mentored and watching them grow into independent clinicians. Other highlights from this experience included creating a holiday “Fun Rounds” video with Sunnybrook residents and staff.
“It was an unparalleled opportunity to hone my teaching, mentorship and leadership skills while contributing to the warm and inclusive environment for which Sunnybrook is well known,” she says.
During this time, she was fortunate to receive support from Sunnybrook and internal medicine program leaders to complete a Master of Science in Quality Improvement and Patient Safety at the Institute of Health Policy, Management and Evaluation.
“I was introduced to the principles of QI during my first year of medical school, where we had the memorable experience of drafting a surprisingly controversial process map on how to take a shower,” says Dr. Tan. “Through various projects in medical school and residency, I gained an appreciation for how QI differs from other types of research. I was drawn to its emphasis on understanding the problem at a local level, engaging key stakeholders in development of solutions and conducting small but rapid tests of change.”
She ultimately chose QI as her research focus due to its power to transform problems encountered in everyday clinical work into meaningful interventions that improve patient care.
Following her CMR year, Dr. Tan entered the Geriatric Medicine program at U of T. She thoroughly enjoyed every step of her training and feels incredibly fortunate to have worked with and learned from the Divisional Director, Dr. Barbara Liu, in clinic every week.
“In geriatrics, we get to be the ultimate detectives while learning about our patients as people,” she says. “We explore the richness of their past, identify what matters most in the present and strive together to improve the future. As a bonus, we also receive great life advice like always sunblock the back of your hands!”
Dr. Tan was honoured to be selected as a Lead Resident for the Geriatric Medicine program during the 2023-24 academic year. Unlike the CMR role, this position is completed at the same time as residency training and is program-wide rather than specific to a single hospital. The role involved collaborating with her Geriatric Medicine Program Director, Dr. Dov Gandell, to synthesize resident feedback and brainstorm ideas to further enhance the training program. She also recruited speakers for academic half-days to complement the residents’ clinical experiences and help them prepare for key topics on the Royal College exam.
This past July, Dr. Tan began her PGY-7 specializing in Clinical Pharmacology and Toxicology (CPT) after completing her training in Geriatric Medicine. Looking back, she says her interest in CPT began with a fascination with the unknown, coupled with a healthy dose of fear.
It was an area she was unfamiliar with until her rotation at Sunnybrook in her second year of residency. By that time, she had already encountered a range of adverse drug reactions and interactions, including some that were life-threatening.
“During the rotation, I found it deeply satisfying to identify the most likely culprit drugs and learn how we can reduce the risk of these events before they occur,” she says. “I also developed a deeper understanding of pharmacokinetic and pharmacodynamic changes that occur with age and an appreciation for how well CPT and Geriatric Medicine complement each other. It was thanks to my mentors, Dr. David Juurlink and Dr. Joanne Ho, that I realized combining the two would be possible, and that clinical pharmacologists can be quite humourous.”
Today, Dr. Tan is working with another mentor – assistant professor and Director of the Co-Learning Curriculum in the Department of Medicine, Dr. Katrina Piggott – on a deprescribing project in long-term care (LTC). As a person’s medication list grows, the risk of experiencing an adverse drug reaction or interaction increases. Since the benefits and risks of medications can change over time, it’s important to regularly consider whether they should be continued or deprescribed.
Choosing Wisely Canada recently updated their recommendations to emphasize the need for regular reassessment of medications for dementia and to consider deprescribing them if the risks outweigh the benefits. Even though deprescribing these medications has been shown to be safe and well-tolerated in LTC, these practices are not yet routine.
“Given the location and well-established quality culture, we chose Sunnybrook’s LTC home as the first site for our project,” says Dr. Tan. “In 2023, we completed a root cause analysis informed by direct observation of medication reviews, physician surveys, chart review and interviews with physicians, nurses, allied health and caregivers.”
Drs. Tan and Piggott then developed a deprescribing toolkit that includes a decision support algorithm, clinician evidence summary, patient/family support package and an electronic medical record documentation tool with automated integration into medication reviews. Initial results have demonstrated an improvement in the frequency of dementia medication reassessments and trials of deprescribing in appropriate candidates. Post-implementation data collection is still ongoing.
To their knowledge, this is the first study to examine the implementation of these recommendations in LTC. The long-term goal is to expand these efforts to improve the reassessment of dementia medications in LTC homes across Canada.
As a geriatrician and soon-to-be clinical pharmacologist and toxicologist, Dr. Tan looks forward to practicing in both subspecialties and at their intersection, with a research focus in QI and patient safety.
“During my residency training, I was incredibly fortunate to learn from renowned educators and receive guidance from generous mentors,” she says. “I endeavour to create similarly positive training experiences for future residents and medical students while working together to provide the best possible care for our patients.”
