Teaching and Evaluating Physicianship The Healer The Professional

Work in Progress What we have accomplished Our hopes for the future

What is Physicianship?

The Physician Has Two Roles Healer Professional

The two roles Served simultaneously. Analyzed separately.

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

Medicine’s Values Are Derived From Both The Healer and the Professional

The Primary Role is that of the Healer

Society uses the concept of the professional as a means of organizing the delivery of complex services which it requires, including that of the healer. “The Professional Model”

Other Models are Available > Bureaucratic Free Market Neither Share the Values of the Healer none pure

The Social Contract TRUST Medicine Society fulfill the role of the healer guaranteed competence altruistic service morality and integrity promotion of the public good openness accountability Society monopoly autonomy trust and respect self-regulation adequate resources status and rewards financial non-financial TRUST

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

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

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

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 and the Literature on Professionalism In Press, “Teaching and Learning in Medicine”

Attributes Professional Healer Caring and compassion Insight Openness Respect for the healing function Respect patient dignity and autonomy Presence Autonomy Self-regulation Responsibility to society Team work Competence Commitment Confidentiality Altruism Integrity and honesty Morality and ethics Responsibility to the profession Professional Healer

Each attribute will be reflected (or not) by appropriate (or inappropriate) behavior. These behaviors can be observed and evaluated.

The Challenge How to impart knowledge of Physicianship to students and residents. How to encourage behavior characteristic of the good physician.

By concentrating on the role of the Professional we risk neglecting that of the Healer - in spite of overlap THEY ARE DIFFERENT

General Principles Integrated approach throughout faculty for undergraduate and postgraduate education. Support of Dean’s Office and Chairs. Multiple techniques of teaching. The International Charter formal teaching small groups independent activities role models - attendings - residents other

The International Charter General Principles Evaluate what is taught. The International Charter Faculty and Resident development essential.

Faculty Development 1) Teaching Professionalism - think tank (20) 2) Teaching Professionalism: Dean’s Invitation (40) 3) Evaluating Professionalism - think tank (20) 4) Evaluating Physicianship - (90) Behaviors Identified 150 Faculty members and residents have participated. Large pool of trained teachers and role models.

McGill: 1996 - 2003 for all residents (CanMeds) Body Donor Service: 1992 Prof 101 followed by small groups: 1997 Elective: The Profession and Society: 1999 White Coat Ceremony: 2000 Mandatory half day on professionalism 2000 for all residents (CanMeds) Professionalism 101 to incoming students 2003 201 to 1st year students 2004 20 students Pledge

Assessment: teaching • episodic • ineffective evaluation • methods primitive the role of the healer not addressed explicitly.

Program on Physicianship to teach the role of the Healer and The Professional. to promote behaviors characteristic of both. to evaluate knowledge of both roles to evaluate behaviors characteristic of both.

Four Committees The Healer The Professional Evaluation Post Graduate Education

Recommendations Undergraduate A longitudinal program on physicianship throughout 4 years of medical school. Distinct approaches to the Healer and the Professional. Incorporate existing activities including ethics. Create new learning experiences. Revise evaluation system - global rating scale - miniCEX All students must successfully complete program.

Recommendations Postgraduate All residents must master the cognitive base of professionalism. Self reflection must be promoted - small groups - ? portfolios revise evaluation system - global rating scale - miniCEX

Content Whole class (Flagship) activities at regular intervals Lectures small groups ethics small groups introduction to the cadaver small groups body donor service white coat ceremony 4th year seminars

Content unit specific activities (small group) pre-clinical clinical humanism/narrative medicine spirituality palliative care medicine community service portfolio (self-reflection, self-assessment)

Evaluation ALL ATTRIBUTES MUST BE EVALUATED USING AT LEAST ONE METHOD longitudinal - 4 years multiple methods knowledge - mcq etc. - (do often) global rating scale - UCSF, Maastrict critical incidents portfolio ? MiniCEX ALL ATTRIBUTES MUST BE EVALUATED USING AT LEAST ONE METHOD

Faculty Development essential - includes residents knowledge role modeling evaluation Requires resources

Resources Assoc/Assist Dean for Physicianship Infrastructure Support - financial and other

Summary The role of the Healer and the Professional must be taught. Must start with agreed-upon definitions. The teaching of physicianship should represent a major commitment of the faculty. It should be taught and evaluated in a planned way throughout the curriculum.

“The most important problem for the future of professionalism is neither economic nor structural but cultural and ideological. The most important problem is its soul” Freidson, 2001