Ian Hart “The real role of medical teachers

is to promote, encourage, teach and facilitate capability and enthusiasm for self-directed and lifelong learning”

“I like to make things happen”

OTTAWA CONFERENCE

CAME

““THOU SHALT NOT THOU SHALT NOT might reach the head, might reach the head,

but it takes but it takes ONCE UPON A TIME ONCE UPON A TIME

to reach the heart”to reach the heart”

Ascribed to P. Pullman: New Yorker, Dec.26 2005Ascribed to P. Pullman: New Yorker, Dec.26 2005

Physicians must both Physicians must both understand professionalism understand professionalism

(which many do not) (which many do not) and live it every dayand live it every day

(which many do)(which many do)

This is Important to SocietyThis is Important to Society

““Neither economic incentives, norNeither economic incentives, nortechnology, nor administrative controltechnology, nor administrative controlhas proved an effective surrogate for the has proved an effective surrogate for the commitment to integrity evoked in the commitment to integrity evoked in the ideal of professionalismideal of professionalism””

Sullivan, 1995Sullivan, 1995

PROFESSIONALISMPROFESSIONALISM• Traditionally taught by role modelsTraditionally taught by role models

• It remains an essential methodIt remains an essential method

• It alone is no longer sufficientIt alone is no longer sufficient

• Role models must understand Role models must understand professionalismprofessionalism

The ChallengeThe Challenge• How to impart knowledge of How to impart knowledge of

professionalism to students, residents professionalism to students, residents and faculty.and faculty.

• How to encourage the behaviors How to encourage the behaviors characteristic of the good physician.characteristic of the good physician.

• • Effective teaching of professionalism must Effective teaching of professionalism must reach reach bothboth the head and the heart the head and the heart

•• This is the preferred learning style of the This is the preferred learning style of the present generationpresent generation

THE LITERATURETHE LITERATURE TWO APPROACHESTWO APPROACHES• Teach it explicitly:Teach it explicitly: definitions/list of traitsdefinitions/list of traits• Teach it as a moral endeavor:Teach it as a moral endeavor: altruism/service/role modeling/ altruism/service/role modeling/

experiential learningexperiential learning

MUST DO BOTH !MUST DO BOTH !

Teaching aloneTeaching aloneremainsremains theoreticaltheoretical

Experiential learning aloneExperiential learning alone selective/disorganized knowledge of selective/disorganized knowledge of

professionalism and professional professionalism and professional obligationsobligations

EDUCATIONAL THEORYEDUCATIONAL THEORY

SITUATED LEARNING (SITUATED LEARNING (Brown et al, 1989Brown et al, 1989))

• OBJECTIVE: transfer knowledge from OBJECTIVE: transfer knowledge from abstract and theoretical to useful and useableabstract and theoretical to useful and useable

• METHOD: embed learning in authentic METHOD: embed learning in authentic activitiesactivities

Before knowledge can be embedded Before knowledge can be embedded in authentic activities it in authentic activities it MUSTMUST

first be acquiredfirst be acquired

HOW HOW • Cognitive base Cognitive base -- teach it explicitlyteach it explicitly

• Self-reflection Self-reflection -- encourage the active encourage the active processprocess

• Role modeling Role modeling -- requires knowledge and requires knowledge and self-awareness self-awareness

• The environment The environment -- must support must support professional valuesprofessional values

UndergraduateUndergraduate PostgraduatePostgraduate

Year 1Year 1 Year 4 Year 4

Level of SophisticationLevel of Sophistication

“ “social contract”social contract”

Teaching ProfessionalismTeaching Professionalism

capacity to capacity to personalizepersonalizeprofessionalismprofessionalism

Imparting the Imparting the Cognitive Base Cognitive Base “Professionalism“Professionalism””

Promoting Self-Promoting Self-ReflectionReflection

> > > > > > > > > > > > > > > > > > > > >>

The Cognitive BaseThe Cognitive Base• Requires an institutionally accepted definition.Requires an institutionally accepted definition.• IncludesIncludes : the origins and evolution of the concept : the origins and evolution of the concept

of professionalism. of professionalism.: its attributes and the obligations : its attributes and the obligations

necessary to sustain it. necessary to sustain it.: its relation to medicine’s social contract.: its relation to medicine’s social contract.

TELL A STORYTELL A STORY

Self-ReflectionSelf-Reflection• Definition:Definition: purposeful thought provoked by learner’s purposeful thought provoked by learner’s unease when they recognize that their unease when they recognize that their understanding is incompleteunderstanding is incomplete Dewey, 1933Dewey, 1933

• Requirements:Requirements: 1. something to reflect on 1. something to reflect on 2. time to reflect and role models2. time to reflect and role models 3. motivation3. motivation

Albanese: Medical Education, 2006Albanese: Medical Education, 2006

The Physician Has Two RolesThe Physician Has Two Roles

• HealerHealer

• ProfessionalProfessional

• Served simultaneouslyServed simultaneously

• Analyzed separatelyAnalyzed separately

AntiquityAntiquity

HippocratesHippocrates

technologytechnology““curing”curing”

The PresentThe Present

Healing and Professionalism Healing and Professionalism Healing and Professionalism Healing and Professionalism The concept of the The concept of the healerhealer The concept of the The concept of the professionalprofessional

Code of Code of EthicsEthics

Middle agesMiddle ages““Learned professions”Learned professions”clergy, law, medicineclergy, law, medicine

1850:Legislation1850:Legislation

1900:University linkage1900:University linkage

The PresentThe Present

ScienceScience

CompetenceCompetenceCommitmentCommitmentConfidentialityConfidentialityAltruismAltruism

Integrity / HonestyIntegrity / Honesty

codes of ethicscodes of ethicsMorality / Ethical Morality / Ethical BehaviorBehaviorResponsibility to the Responsibility to the professionprofession

Autonomy Autonomy

Self-regulationSelf-regulation

associationsassociations

institutionsinstitutions

Responsibility Responsibility to societyto society

Team workTeam work

Caring/ compassionCaring/ compassion

InsightInsight

OpennessOpennessRespect for the Respect for the healing functionhealing functionRespect patientRespect patient dignity/dignity/ autonomyautonomy

Presence Presence

Physician

Healer Professional

The Primary Role is that The Primary Role is that of the Healerof the Healer

Professionalism as the word is Professionalism as the word is used generally includes both rolesused generally includes both roles

we usewe use “PHYSICIANSHIP” “PHYSICIANSHIP”

To HealTo Heal

To make whole or sound in bodily To make whole or sound in bodily conditions; to free from disease or ailment, conditions; to free from disease or ailment, to restore to health or soundness.to restore to health or soundness.

Oxford English Dictionary, 1985Oxford English Dictionary, 1985

DefinitionDefinition Profession Profession

DefinitionDefinition Profession Profession

““An occupation whose core element is work based upon the mastery of a complex body of An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. These and morality, altruism, and to the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.”members are accountable to those served and to society.”

Derived from the Oxford English Derived from the Oxford English Dictionary (1985) and the literature on Dictionary (1985) and the literature on professionalismprofessionalism

Cruess, Johnston, Cruess “Teaching andCruess, Johnston, Cruess “Teaching and Learning in Medicine”, 2004Learning in Medicine”, 2004

• The social contract in health care The social contract in health care hinges on professionalism.hinges on professionalism.

• It serves as the basis for the It serves as the basis for the expectations of medicine and expectations of medicine and society.society.

““The rights and duties of the state and The rights and duties of the state and its citizens are reciprocal and the its citizens are reciprocal and the recognition of this reciprocity recognition of this reciprocity constitutes a relationship which by constitutes a relationship which by analogy can be called a social contract”analogy can be called a social contract”

Gough: “The Social Contract”, 1957

The Social ContractThe Social ContractA mix ofA mix of:: •• the explicit and the implicitthe explicit and the implicit

•• the written and the unwritten the written and the unwritten

-- licensing laws, health care licensing laws, health care legislation, codes of ethics, legislation, codes of ethics,

the Charterthe Charter

•• legal and moral obligations legal and moral obligations

•• the universal and the localthe universal and the local

Constantly evolvingConstantly evolving (being renegotiated) (being renegotiated)

The Social ContractThe Social ContractSociety’s Expectations of MedicineSociety’s Expectations of Medicine

• to fulfill the role of the healerto fulfill the role of the healer• assured competenceassured competence

• altruistic servicealtruistic service

• morality / integrity / honestymorality / integrity / honesty

codes of ethicscodes of ethics

• accountabilityaccountability

• transparencytransparency

• source of objective advicesource of objective advice

• promotion of the public goodpromotion of the public good

Medicine’s Expectations of SocietyMedicine’s Expectations of Society

• trusttrust• autonomyautonomy• self-regulationself-regulation• health care systemhealth care system

– value-ladenvalue-laden– adequately fundedadequately funded

• role in public policyrole in public policy• patients accept responsibility for healthpatients accept responsibility for health• monopolymonopoly• rewards rewards – – non-financialnon-financial

• • respectrespect• • statusstatus

–– financialfinancial

Individual and Collective ResponsibilitiesIndividual and Collective Responsibilities

The McGill ExperienceThe McGill Experience1997 - 20061997 - 2006

A Work in ProgressA Work in Progress

The result of the Efforts of Many The result of the Efforts of Many Individual Faculty MembersIndividual Faculty Members

GENERAL PRINCIPALS• Integrated approach throughout undergraduate Integrated approach throughout undergraduate and postgraduate education.and postgraduate education.• Activities throughout the curriculumActivities throughout the curriculum• Support of Dean’s office & ChairsSupport of Dean’s office & Chairs• Multiple techniques of teaching.Multiple techniques of teaching.

» Formal Teaching Formal Teaching » small groupssmall groups» independent activitiesindependent activities» role models -facultyrole models -faculty

- residents- residents» Self-ReflectionSelf-Reflection

• Evaluation linked to teachingEvaluation linked to teaching Cruess & CruessCruess & Cruess

• Faculty Development EssentialFaculty Development Essential Medical Teacher,2006Medical Teacher,2006

»

Faculty DevelopmentFaculty DevelopmentResultsResults

• 4 sessions on teaching or evaluating professionalism over 3 years4 sessions on teaching or evaluating professionalism over 3 years

• 152 faculty members attended at least one half day session.152 faculty members attended at least one half day session.

• Agreed on the cognitive base and behaviors reflecting Agreed on the cognitive base and behaviors reflecting professionalism.professionalism.

• Developed methods of formal instruction/experiential learningDeveloped methods of formal instruction/experiential learning

• Participants becameParticipants became skilled group leaders/trained role models.skilled group leaders/trained role models.

• Led to curricular changeLed to curricular change..

• ? Altered the environment.? Altered the environment.

Steinert, Cruess, Cruess and Snell Steinert, Cruess, Cruess and Snell Medical Education, 2005 Medical Education, 2005

• A longitudinal 4 year program on Physicianship A longitudinal 4 year program on Physicianship

• Distinct approaches to the Distinct approaches to the HealerHealer and the and the Professional.Professional.

• Redefinition of the clinical methodRedefinition of the clinical method

• Incorporation of Incorporation of existing activitiesexisting activities including ethics. including ethics.

• Creation of Creation of new learning experiencesnew learning experiences..

• Revision of evaluation system Revision of evaluation system - global rating scale- global rating scale - P-MEX- P-MEX

• All students required to complete the program.All students required to complete the program.

• Consultants: Eric Cassell, Rita CharonConsultants: Eric Cassell, Rita Charon

Undergraduate- NEWUndergraduate- NEW

Content-Whole ClassContent-Whole Class ““Flagship activities”-Flagship activities”- at regular intervals- requiredat regular intervals- required

– lectures small groupslectures small groups

– ethics small groupsethics small groups– communication skills (Calgary/Cambridge)communication skills (Calgary/Cambridge)– introduction to the cadaver small groupsintroduction to the cadaver small groups– body donor servicebody donor service– white coat ceremonywhite coat ceremony– palliative care medicinepalliative care medicine– 4th year seminars - “The Social Contract and You”4th year seminars - “The Social Contract and You”

Prof 401- 6 hoursProf 401- 6 hours

Prof 101 - 1st yrProf 101 - 1st yrProf 201 - 2nd yrProf 201 - 2nd yrProf 301 – 3Prof 301 – 3rdrd year year<<

Content- Individual CoursesContent- Individual Courses

• unit specific activities (small group)unit specific activities (small group)

pre-clinicalpre-clinicalclinicalclinical

• humanism/narrative medicinehumanism/narrative medicine

• spiritualityspirituality

• community servicecommunity service

OSLER SCHOLARSOSLER SCHOLARS

• Mentors to a small group (6) for 4 yearsMentors to a small group (6) for 4 years• Selected from a student-generated list of skilled Selected from a student-generated list of skilled

teachers and role modelsteachers and role models• Integral to the Physicianship Program- mandated Integral to the Physicianship Program- mandated

activities on the Healer and the Professionalactivities on the Healer and the Professional• Dedicated faculty development programDedicated faculty development program• Supervise “Physicianship Portfolios”Supervise “Physicianship Portfolios”• SalariedSalaried

PROGRAM EVALUATION

• Too early- only 10 years!Too early- only 10 years!• faculty and student knowledge and faculty and student knowledge and awareness- ?? awareness- ??

change in the environmentchange in the environment• Ultimate evaluationUltimate evaluation - - patient satisfactionpatient satisfaction -- physician satisfaction physician satisfaction -- rate of physician disciplinary actions rate of physician disciplinary actions -- the status of the profession in societythe status of the profession in society

““The practice of medicine is an The practice of medicine is an art, not a trade; a calling, not a art, not a trade; a calling, not a business: a calling in which your business: a calling in which your heartheart will be exercised equally will be exercised equally with your with your headhead””

Osler: The Master Word in Medicine

In “Aequanimitas”