Teaching and Evaluating Teaching and Evaluating PhysicianshipPhysicianship

The HealerThe Healer The ProfessionalThe Professional

Work in ProgressWork in Progress

• What we have accomplishedWhat we have accomplished

• Our hopes for the futureOur hopes for the future

What is Physicianship?What is Physicianship?

The Physician Has Two RolesThe Physician Has Two Roles

• HealerHealer

• ProfessionalProfessional

The two rolesThe two roles• Served simultaneously.Served simultaneously.• Analyzed separately.Analyzed separately.

AntiquityAntiquity

HippocratesHippocrates

technologytechnology““curing”curing”

The PresentThe Present

Professionalism and MedicineProfessionalism and MedicineThe concept of the healerThe concept of the healer The concept of the professionalThe concept of the professional

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

Medicine’s Values Are Medicine’s Values Are Derived From Both The Derived From Both The

Healer and the ProfessionalHealer and the Professional

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

Society uses the concept of the Society uses the concept of the professional as a means of professional as a means of

organizing the delivery of complex organizing the delivery of complex services which it requires, services which it requires,

including that of the healer.including that of the healer.

““The Professional Model”The Professional Model”

Other Models are AvailableOther Models are Available

• BureaucraticBureaucratic• Free MarketFree Market

Neither Share the Values of the HealerNeither Share the Values of the Healer

none purenone pure>

The Social ContractThe Social ContractMedicineMedicine

• fulfill the role of the healerfulfill the role of the healer• guaranteed competenceguaranteed competence• altruistic servicealtruistic service• morality and integritymorality and integrity• promotion of the public goodpromotion of the public good• opennessopenness• accountabilityaccountability

SocietySociety• monopolymonopoly• autonomyautonomy• trust and respecttrust and respect• self-regulationself-regulation• adequate resourcesadequate resources• status and rewardsstatus and rewards

financialfinancial non-financialnon-financial

TRUSTTRUST

• 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 both medicine expectations of both medicine and society.and society.

• To preserve values in changing times, To preserve values in changing times, Physicians must understand the linked Physicians must understand the linked roles of the healer and the professional.roles of the healer and the professional.

• They must be taught.They must be taught.

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 DictionaryOxford English Dictionary

DefinitionDefinition Profession Profession

““An occupation whose core element is work based upon the mastery of a 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 complex body of 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 some department of science or 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 is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. These commitments 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 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 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. right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.”Professions and their members are accountable to those served and to society.”Derived from the Oxford English Derived from the Oxford English Dictionary and the Literature on ProfessionalismDictionary and the Literature on Professionalism

In Press, “Teaching and Learning in Medicine”In Press, “Teaching and Learning in Medicine”

CompetenceCompetenceCommitmentCommitmentConfidentialityConfidentialityAltruismAltruismIntegrity and honestyIntegrity and honestyMorality and ethicsMorality and ethicsResponsibility to the Responsibility to the professionprofession

Autonomy Autonomy Self-regulationSelf-regulationResponsibility Responsibility to societyto societyTeam workTeam work

Caring and compassionCaring and compassionInsightInsightOpennessOpennessRespect for the Respect for the healing functionhealing functionRespect patientRespect patient dignity anddignity and autonomyautonomyPresence Presence

Healer Professional

Physician

• Each attribute will be reflected (or not) Each attribute will be reflected (or not) by appropriate (or inappropriate) by appropriate (or inappropriate) behavior.behavior.

• These behaviors can be observed and These behaviors can be observed and evaluatedevaluated..

• How to impart knowledge of How to impart knowledge of Physicianship to students and residents.Physicianship to students and residents.

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

The ChallengeThe Challenge

By concentrating on the role of By concentrating on the role of the Professional we risk the Professional we risk

neglecting that of the Healer - neglecting that of the Healer - in spite of overlap in spite of overlap

THEY ARE DIFFERENTTHEY ARE DIFFERENT

General PrinciplesGeneral Principles• Integrated approach throughout faculty for undergraduate and Integrated approach throughout faculty for undergraduate and

postgraduate education.postgraduate education.• Support of Dean’s Office and Chairs.Support of Dean’s Office and Chairs.• Multiple techniques of teaching.Multiple techniques of teaching.

» The International CharterThe International Charter» formal teachingformal teaching» small groupssmall groups» independent activitiesindependent activities» role models - attendingsrole models - attendings

- residents- residents» otherother

General PrinciplesGeneral Principles

• Evaluate what is taught.Evaluate what is taught.The International CharterThe International Charter

• Faculty and Resident development Faculty and Resident development essential.essential.

Faculty DevelopmentFaculty Development1)1) Teaching Professionalism - think tank (20) Teaching Professionalism - think tank (20)2)2) Teaching Professionalism: Dean’s Invitation (40) Teaching Professionalism: Dean’s Invitation (40)3)3) Evaluating Professionalism - think tank (20) Evaluating Professionalism - think tank (20)4)4) Evaluating Physicianship - (90) Evaluating Physicianship - (90)

Behaviors IdentifiedBehaviors Identified150 Faculty members and residents have participated.150 Faculty members and residents have participated.Large pool of trained teachers and role models.Large pool of trained teachers and role models.

McGill: 1996 - 2003McGill: 1996 - 2003• Body Donor Service:Body Donor Service: 19921992• Prof 101 followed by small groups:Prof 101 followed by small groups: 19971997• Elective: The Profession and Society:Elective: The Profession and Society: 19991999

• White Coat Ceremony:White Coat Ceremony: 2000 2000

• Mandatory half day on professionalismMandatory half day on professionalism 20002000for all residents (CanMeds)for all residents (CanMeds)

• Professionalism 101 to incoming studentsProfessionalism 101 to incoming students 20032003201 to 1st year students201 to 1st year students 20042004

PledgePledge

20 students20 students

teachingteaching •• episodic episodic•• ineffectiveineffective

evaluationevaluation • • methods primitivemethods primitive•• ineffectiveineffective

the role of the healer not the role of the healer not addressed explicitly.addressed explicitly.

Assessment:Assessment:

Program on PhysicianshipProgram on Physicianship• to teach the role of the Healer and The to teach the role of the Healer and The

Professional.Professional.• to promote behaviors characteristic of both.to promote behaviors characteristic of both.• to evaluate knowledge of both rolesto evaluate knowledge of both roles• to evaluate behaviors characteristic of both.to evaluate behaviors characteristic of both.

Four CommitteesFour Committees

The HealerThe HealerThe ProfessionalThe ProfessionalEvaluationEvaluationPost Graduate EducationPost Graduate Education

RecommendationsRecommendations• A longitudinal program on physicianship throughout 4 A longitudinal program on physicianship throughout 4

years of medical school.years of medical school.• Distinct approaches to the Healer and the Professional.Distinct approaches to the Healer and the Professional.• Incorporate existing activities including ethics.Incorporate existing activities including ethics.• Create new learning experiences.Create new learning experiences.• Revise evaluation system - global rating scaleRevise evaluation system - global rating scale

- miniCEX- miniCEX• All students must successfully complete program.All students must successfully complete program.

UndergraduateUndergraduate

RecommendationsRecommendations• All residents must master the cognitive base of All residents must master the cognitive base of

professionalism.professionalism.• Self reflection must be promotedSelf reflection must be promoted

- small groups- small groups- ? portfolios- ? portfolios

• revise evaluation system revise evaluation system - global rating scale- global rating scale- miniCEX- miniCEX

PostgraduatePostgraduate

Basis of Medicine & Dentistry (BOM) Unit 1 Unit 2 Unit 3 Unit 4 Unit 5 Unit 6 Unit 7

Introduction to Clinical Medicine (ICM)Unit 8 Unit 9

September October November December January February March April May June July AugustHostDefense &HostParasite(2 wks)

Pathobiology, Treatment &Prevention of Disease

(14 wks)

WCT

Intro toEmergencyMed/Neurology/Oncology

ITPM

ProfessionalSkills:ICSEthics & LawEBM

(4 wks)

Intro to InternalMedicine

(7 wks)

Intro to Surgery/Anesthesia/

Radiology/Ophthalmology

(7 wks)Family Medicine

(7 wks)

Elective#1

(4 wks)

Vacation /Research

* * 4 * 5 PHYSICIANSHIP * *

Practice of Medicine (POM) ClerkshipSeptember October November December January February March April May June July August

Intro toPsychiatry/Pediatrics/Ob & Gyn/Hosp Pract

(4 wk)

Pediatrics

(8 wks)

Obstetrics &Gynecology

(8 wks)

Surgery

(8 wks)

Psychiatry

(8 wks)

Internal Medicine

(8 wks)

Elective#2

(4 wks)

GeriatricMedicine

(4 wks) * * * * PHYSICIANSHIP 6 * * *

Back to Basics (BTB)September October November December January February March April

Seminar Options (3) (Basic Sciences)

Communication Plus

FamilyMedicine

(4 wks)

Elective # 3

(4 wks)

Vacation

(4 wks)

Elective # 4

(4 wks)

SeminarOption

(Humanities)

(3 wks)

Medicine &Society

(4 wks) (3 wks) (3 wks) (3 wks)

1 = Lecture and small groups to incoming students 2 = Introduction to the cadaver 3 = Body Donor Ceremony 4 = White Coat Ceremony 5 = Lecture and small groups prior to clerkship 6 = Whole class activity to be developed 7 = Seminars on Professionalism in Society

= ethics lectures and small group in ITP and second year plus unit specific teaching of ethics * = unit specific teaching of physicianship

* 7 PHYSICIANSHIP

September October November December January February March April May June July AugustMolecules,

Cells &Tissues

(4 wks)

Gas, Fluids & Electrolytes

(9 wks)

Life Cycle

(3 wks)

Endocrinology,Metabolism & Nutrition

(7 wks)

Musculo-skeletal &

Blood

(4 wks)

Nervous System & SpecialSenses

(8 wks)

HostDefense &

HostParasite(5 wks)

Vacation/Research

ITP 1 2 * * PHYSICIANSHIP * * * 3

ContentContent• Whole class (Flagship) activities at regular intervalsWhole class (Flagship) activities at regular intervals

– Lectures small groupsLectures small groups– ethics small groupsethics small groups– introduction to the cadaver small groupsintroduction to the cadaver small groups– body donor servicebody donor service– white coat ceremonywhite coat ceremony– 4th year seminars4th year seminars

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

pre-clinicalpre-clinicalclinicalclinical

• humanism/narrative medicinehumanism/narrative medicine• spiritualityspirituality• palliative care medicinepalliative care medicine• community servicecommunity service• portfolio (self-reflection, self-assessment)portfolio (self-reflection, self-assessment)

EvaluationEvaluation• longitudinal - 4 yearslongitudinal - 4 years• multiple methodsmultiple methods

– knowledge - mcq etc. - (do often)knowledge - mcq etc. - (do often)– global rating scale - UCSF, Maastrictglobal rating scale - UCSF, Maastrict– critical incidentscritical incidents– portfolioportfolio– ? MiniCEX? MiniCEX

ALL ATTRIBUTES MUST BE EVALUATED USING ALL ATTRIBUTES MUST BE EVALUATED USING AT LEAST ONE METHODAT LEAST ONE METHOD

Faculty DevelopmentFaculty Development– essential - includes residentsessential - includes residents– knowledge role modelingknowledge role modeling– evaluationevaluation

Requires resourcesRequires resources

ResourcesResourcesAssoc/Assist Dean for PhysicianshipAssoc/Assist Dean for Physicianship

InfrastructureInfrastructureSupport - financial and Support - financial and

otherother

SummarySummary• The role of the Healer The role of the Healer andand the Professional must the Professional must

be taught.be taught.• Must start with agreed-upon definitions.Must start with agreed-upon definitions.• The teaching of physicianship should represent a The teaching of physicianship should represent a

major commitment of the faculty.major commitment of the faculty.• It should be taught and evaluated in a planned It should be taught and evaluated in a planned

way throughout the curriculum.way throughout the curriculum.

““The most important problem The most important problem for the future of professionalism is for the future of professionalism is neither economic nor structural but neither economic nor structural but cultural and ideological. The most cultural and ideological. The most important problem is its soul”important problem is its soul”

Freidson, 2001