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 might reach the head, but it takes ONCE UPON A TIME to reach the heart” Ascribed to P. Pullman: New Yorker, Dec

Physicians must both understand professionalism (which many do not) and live it every day (which many do)

This is Important to Society This is Important to Society “Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism ” Sullivan, 1995

PROFESSIONALISM PROFESSIONALISM 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 professionalismRole models must understand professionalism

The Challenge The Challenge How to impart knowledge of professionalism to students, residents and faculty.How to impart knowledge of professionalism to students, residents and faculty. How to encourage the behaviors characteristic of the good physician.How to encourage the behaviors characteristic of the good physician.

Effective teaching of professionalism must reach both the head and the heart This is the preferred learning style of the present generation Effective teaching of professionalism must reach both the head and the heart This is the preferred learning style of the present generation

THE LITERATURE THE LITERATURE TWO APPROACHES TWO APPROACHES Teach it explicitly:Teach it explicitly: definitions/list of traits definitions/list of traits Teach it as a moral endeavor:Teach it as a moral endeavor: altruism/service/role modeling/ experiential learning altruism/service/role modeling/ experiential learning

MUST DO BOTH ! Teaching alone remains theoretical Experiential learning alone selective/disorganized knowledge of professionalism and professional obligations

EDUCATIONAL THEORY EDUCATIONAL THEORY SITUATED LEARNING (Brown et al, 1989) OBJECTIVE: transfer knowledge from abstract and theoretical to useful and useableOBJECTIVE: transfer knowledge from abstract and theoretical to useful and useable METHOD: embed learning in authentic activitiesMETHOD: embed learning in authentic activities

Before knowledge can be embedded in authentic activities it MUST first be acquired

HOW HOW Cognitive base -teach it explicitlyCognitive base -teach it explicitly Self-reflection -encourage the active processSelf-reflection -encourage the active process Role modeling -requires knowledge and self-awarenessRole modeling -requires knowledge and self-awareness The environment -must support professional valuesThe environment -must support professional values

UndergraduatePostgraduate UndergraduatePostgraduate Year 1 Year 4  Level of Sophistication “social contract” “social contract” Teaching Professionalism  capacity to personalize professionalism Imparting the Cognitive Base “Professionalism ” Promoting Self- Reflection > > > > > > > > > > > > > > > > > > > > > >

The Cognitive Base The Cognitive Base Requires an institutionally accepted definition.Requires an institutionally accepted definition. Includes: the origins and evolution of the concept of professionalism.Includes: the origins and evolution of the concept of professionalism. : its attributes and the obligations necessary to sustain it. : its relation to medicine’s social contract. TELL A STORY TELL A STORY

Self-Reflection Self-Reflection Definition: purposeful thought provoked by learner’sDefinition: purposeful thought provoked by learner’s unease when they recognize that their unease when they recognize that their understanding is incomplete understanding is incomplete Dewey, 1933 Dewey, 1933 Requirements: 1. something to reflect onRequirements: 1. something to reflect on 2. time to reflect and role models 2. time to reflect and role models 3. motivation 3. motivation Albanese: Medical Education, 2006 Albanese: Medical Education, 2006

The Physician Has Two Roles Healer Healer Professional Professional Served simultaneously Served simultaneously Analyzed separately Analyzed separately

AntiquityHippocratestechnology“curing” The Present Healing and Professionalism The concept of the healer The concept of the professional Code of Ethics Middle ages “Learned professions” clergy, law, medicine 1850:Legislation 1900:University linkage The Present Science

CompetenceCommitmentConfidentialityAltruism Integrity / Honesty codes of ethics codes of ethics Morality / Ethical Behavior Behavior Responsibility to the profession profession AutonomySelf-regulation associations associations institutions institutionsResponsibility to society to society Team work Caring/ compassion InsightOpenness Respect for the healing function healing function Respect patient dignity/ dignity/ autonomy autonomyPresence Physician HealerProfessional

The Primary Role is that of the Healer

Professionalism as the word is used generally includes both roles we use “PHYSICIANSHIP”

To Heal To make whole or sound in bodily conditions; to free from disease or ailment, to restore to health or soundness. Oxford English Dictionary, 1985

Definition Profession “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 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 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 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 members are accountable to those served and to society.” Derived from the Oxford English Dictionary (1985) and the literature on professionalism Derived from the Oxford English Dictionary (1985) and the literature on professionalism Cruess, Johnston, Cruess “Teaching and Cruess, Johnston, Cruess “Teaching and Learning in Medicine”, 2004 Learning in Medicine”, 2004

The social contract in health care hinges on professionalism.The social contract in health care hinges on professionalism. It serves as the basis for the expectations of medicine and society.It serves as the basis for the expectations of medicine and society.

“The rights and duties of the state and its citizens are reciprocal and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract” Gough: “The Social Contract”, 1957

The Social Contract A mix of: the explicit and the implicit the written and the unwritten the written and the unwritten - licensing laws, health care legislation, codes of ethics, - licensing laws, health care legislation, codes of ethics, the Charter the Charter legal and moral obligations legal and moral obligations the universal and the local the universal and the local Constantly evolving (being renegotiated)

The Social Contract Society’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 ethics codes of ethics accountabilityaccountability transparencytransparency source of objective advicesource of objective advice promotion of the public goodpromotion of the public good Medicine’s Expectations of Society trusttrust autonomyautonomy self-regulationself-regulation health care systemhealth care system –value-laden –adequately funded role in public policyrole in public policy patients accept responsibility for healthpatients accept responsibility for health monopolymonopoly rewards – non-financialrewards – non-financial respect respect status status – financial – financial Individual and Collective Responsibilities

The McGill Experience A Work in Progress The result of the Efforts of Many Individual Faculty Members

GENERAL PRINCIPALS Integrated approach throughout undergraduateIntegrated 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 » small groups » independent activities » role models -faculty - residents - residents » Self-Reflection Evaluation linked to teaching Cruess & CruessEvaluation linked to teaching Cruess & Cruess Faculty Development Essential Medical Teacher,2006Faculty Development Essential Medical Teacher,2006 »

Faculty Development Results 4 sessions on teaching or evaluating professionalism over 3 years 4 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 professionalism.Agreed on the cognitive base and behaviors reflecting professionalism. Developed methods of formal instruction/experiential learningDeveloped methods of formal instruction/experiential learning Participants became skilled group leaders/trained role models.Participants became skilled group leaders/trained role models. Led to curricular change.Led to curricular change. ? Altered the environment.? Altered the environment. Steinert, Cruess, Cruess and Snell Medical Education, 2005 Steinert, Cruess, Cruess and Snell Medical Education, 2005

A longitudinal 4 year program on PhysicianshipA longitudinal 4 year program on Physicianship Distinct approaches to the Healer and the Professional.Distinct approaches to the Healer and the Professional. Redefinition of the clinical methodRedefinition of the clinical method Incorporation of existing activities including ethics.Incorporation of existing activities including ethics. Creation of new learning experiences.Creation of new learning experiences. Revision of evaluation system - global rating scaleRevision of evaluation system - 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- NEW

Content-Whole Class “Flagship activities”- at regular intervals- required “Flagship activities”- at regular intervals- required – lectures small groups – ethics small groups – communication skills (Calgary/Cambridge) – introduction to the cadaver small groups – body donor service – white coat ceremony – palliative care medicine – 4th year seminars - “The Social Contract and You” Prof hours Prof st yr Prof nd yr Prof 301 – 3 rd year <

Content- Individual Courses unit specific activities (small group)unit specific activities (small group)pre-clinicalclinical humanism/narrative medicinehumanism/narrative medicine spiritualityspirituality community servicecommunity service

OSLER 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 teachers and role modelsSelected from a student-generated list of skilled teachers and role models Integral to the Physicianship Program- mandated activities on the Healer and the ProfessionalIntegral to the Physicianship Program- mandated activities 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 awareness- ?? change in the environment faculty and student knowledge and awareness- ?? change in the environment Ultimate evaluationUltimate evaluation - patient satisfaction - patient satisfaction - physician satisfaction - physician satisfaction - rate of physician disciplinary actions - rate of physician disciplinary actions - the status of the profession in society - the status of the profession in society

“The practice of medicine is an art, not a trade; a calling, not a business: a calling in which your heart will be exercised equally with your head” Osler: The Master Word in Medicine In “Aequanimitas”