IMPLEMENTING PROFESSIONALISM TEACHING & ASSESSMENT General Principles Richard Cruess OC, MD, FRCSC Sylvia Cruess MD, CPSQ McGill University How to reference this document: Cruess R., Cruess S., Implementing Professionalism Teaching & Assessment. CanMEDS Train-the-Trainer Program on Professionalism. 2009

“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)

PROFESSIONALISM PROFESSIONALISM Traditionally taught by role models It remains an essential method It alone is no longer sufficient Role models must understand professionalism

THE CHALLENGE THE CHALLENGE How to impart knowledge of professionalism to students, residents and faculty. 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

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

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

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

HOW Cognitive base - teach it explicitly Experiential learning - provide opportunities Self-reflection - encourage the active process Role modeling - requires knowledge and self- awareness The environment - must support professional values

LEVEL OF LEARNER Imparting core knowledge Promoting self-reflection, application  level of sophistication Medical studentResidency PreclinicalClinical  capacity to personalize Increasing complexity Increasing reflection SOCIAL CONTRACT

OVERALL APPROACH Integrated program throughout undergraduate and postgraduate education. Activities throughout the curriculum Support of Dean’s office & Chairs Multiple techniques of teaching & learning. » formal teaching » experiential learning & self-reflection » small groups » role models -faculty - residents » independent activities Evaluation linked to teaching Faculty Development- Essential Cruess & Cruess Medical Teacher 2006

GENERAL PRINCIPLES 1. INSTITUTIONAL SUPPORT Support of Dean’s office & Chairs Time in Curriculum- modest $$$$ and Human Resources

GENERAL PRINCIPLES 2. ALLOCATION OF RESPONSIBILITY Leader/Champion- respected individual Committee- broad representation PROFESSIONALISM CROSSES DEPARTMENTAL LINES WHAT WILL BE YOUR ROLE?

GENERAL PRINCIPLES 3. THE ENVIRONMENT Formal Curriculum structured program on professionalism Informal Curriculum- Supports Healer Role role models (+/-), pursuit of excellence teamwork, patient-centered Hidden Curriculum institutional priorities, rewards, incentives ALL MUST BE ADDRESSED

GENERAL PRINCIPLES 4. THE COGNITIVE BASE Choose a definition Teach it explicitly and often with increasing levels of sophistication DON’T CHERRY PICK

GENERAL PRINCIPLES 5. EXPERIENTIAL LEARNING & SELF-REFLECTION “Professional identity arises from a long-term combination of experience and reflection on experience” - Hilton & Slotnick, 2005

GENERAL PRINCIPLES 5. EXPERIENTIAL LEARNING & SELF-REFLECTION Provide stage-appropriate experiences Ensure that reflection on these experiences occurs by allowing both time and opportunity Use a variety of methods to provide experiences for reflection

6. ROLE MODELLING Make it explicit-faculty development role models must understand professionalism Support it Reward it Assess it- with consequences (+&-) GENERAL PRINCIPLES

7. FACULTY DEVELOPMENT Affects : knowledge & skill base environment role models Can promote change GENERAL PRINCIPLES

8. CONTINUITY Admissions Undergraduate Post graduate Continuing professional development PROFESSIONALISM DOES NOT CHANGE Teach in each year Stage-appropriate GENERAL PRINCIPLES

9. EVALUATION Knowledge/Behaviors Formative/Summative Students Residents Faculty- informal & hidden curriculum Program- is it working? obligation to society to society GENERAL PRINCIPLES

10. INCREMENTAL APPROACH Difficult to implement comprehensive program simultaneously Design a program for professionalism Start with what is already in place Add new materiel as it is developed GENERAL PRINCIPLES

The McGill Experience 1997 – 2008 A Work in Progress The Result of the Efforts of Many Individual Faculty Members

UNDERGRADUATE - NEW A longitudinal 4 year program on Physicianship Strong support from Dean, Associate Deans, Chairs Faculty Retreat FACULTY DEVELOPMENT New resources- MD Director, Senior Administrator, $$ Distinct approaches to the Healer and the Professional. New admission process- McGill MMI Redefinition of the clinical method

Incorporation of existing activities including ethics, professionalism Creation of new learning experiences. Revision of evaluation system - Global Rating Scale - P-MEX, Faculty Form All students required to complete the program. Program evaluation underway- baseline established Ongoing effort to publish results UNDERGRADUATE - NEW

CONTENT – WHOLE CLASS “ 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 < *were already in place

CONTENT – INDIVIDUAL COURSES unit specific activities (small group) pre-clinical clinical humanism/narrative medicine spirituality community service

OSLER FELLOWS Mentors to a small group (6) for 4 years Selected from a student-generated list of skilled teachers and role models Integral to the Physicianship Program- mandated activities on the Healer and the Professional Dedicated faculty development program Supervise “Physicianship Portfolios” Receive stipends

POST GRADUATE- CanMEDS Occurred Against the Backdrop of the Undergraduate Program Mandatory Half-Day on Professionalism for Each RII Separate structured interactive lecture- THE COGNITIVE BASE- for McGill and non-McGill graduates followed by Combined small-group session using vignettes and discussion of the social contract Faculty member and senior resident co-facilitate each group Each has attended a faculty development workshop Pre/Post assessment of knowledge & opinions

Other large group activities: ethics, malpractice, communication skills, risk management, teamwork, resident wellness Senior residents (Internal Medicine) are group leaders for second-year medical student course Role modeling and guided reflection Improved assessment- behaviors derived from the P-MEX Improving the learning environment faculty development targeting role models assessment of faculty professionalism (testing form) POST GRADUATE - CANMEDS

PROGRAM EVALUATION Too early- only 12 years! faculty, resident, and student knowledge and awareness- ?? change in the environment Ultimate evaluation - patient satisfaction - physician satisfaction - rate of physician disciplinary actions - 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 ”