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AN INTGRATED PROGRAM FOR TEACHING MEDICAL PROFESSIONALISM The McGill Experience 1997-2011
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The Work of Many Individuals
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THE OBJECTIVE It is the function of a medical school to “transmit the culture of medicine and … to shape the novice into an effective practitioner of medicine, to give him the best available knowledge and skills, to provide him with a professional identity so that he comes to think, act, and feel like a physician. Merton et al, 1957
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FLEXNER Scaled “the cognitive peak”
The next mountain involves “non-cognitive skills, and in particular professionalism” Siu & Reiter 2008
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PHYSICIANSHIP Healer& Professional DEFINITION and ATTRIBUTES
ADMISSION CRITERIA TEACHING & LEARNING STUDENTS RESIDENTS FACULTY EVALUATION STUDENTS RESIDENTS FACULTY
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PROFESSION DEFINITION and ATTRIBUTES
FACULTY DEVELOPMENT!! ADMISSION CRITERIA TEACHING & LEARNING STUDENTS RESIDENTS FACULTY EVALUATION STUDENTS RESIDENTS FACULTY Steinert et al. Multiple Publications
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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, to their colleagues, and to society.” • Derived from the Oxford English Dictionary and the literature on professionalism • Cruess, Johnston, Cruess “Teaching and Learning in Medicine”, 2004 7
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Definition: Healer “To make whole or sound in bodily condition: to free from disease or ailment; restore to health or soundness; to cure (of a disease or wound). Oxford English Dictionary
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Attributes Professional Healer PHYSICIAN Healer Professional
Competence Commitment Confidentiality Altruism Trustworthy Integrity / Honesty codes of ethics Morality / Ethical Behavior Responsibility to profession Caring/ compassion listen Insight Openness Respect for the healing function Respect patient dignity/autonomy Advocate for Patient Presence/Accompany Autonomy Self-regulation associations institutions Responsibility to society Team work Professional Healer Based on the Literature 9
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Professionalism as the word is used usually includes both roles McGill Uses “PHYSICIANSHIP” which includes both
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ADMISSION PROCESS
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Frequent Questions Can professionalism be taught?
Shouldn’t professionalism be learned at home? Who let this student into medical school? Why can’t you select the right students, so we wouldn’t have to teach professionalism?
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THE McGILL MMI OBJECTIVES
TO IDENTIFY CANDIDATES WHO ALREADY DEMONSTRATE THE ATTRIBUTES OF THE HEALER AND THE PROFESSIONAL TO PUBLICLY INDICATE THE IMPORTANCE OF THESE ATTRIBUTES
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THE McGILL MMI 10 SCENARIOS- SIMULATION CENTER TRAINED ACTORS
EACH SCENARIO DESIGNED TO ELICIT OBSERVABLE BEHAVIORS REFLECTING DESIRABLE ATTRIBUTES PERFORMANCE ASSESSED BY TRAINED OBSERVERS USING A NUMERICAL SCALE MMI CONSTITUTES 70 % OF FINAL RANKING Razack et al. Med Ed, 2009
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THE McGILL MMI Blueprinted to Physicianship Curriculum
Measures different competencies from GPA, MCAT, autobiographical data, references Three years of experience Different students selected (pilot) Separates candidates: wide, flat bell-shaped curve Excellent internal consistency Well liked by students We expect it to correlate with clinical performance as was found by Eva Razack et al. submitted. 2011
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TEACHING PHYSICIANSHIP The Healer & The Professional UNDERGRADUATE
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BACKGROUND McGill CLERKSHIPS: WORKING TOWARDS INTEGRATED MODEL
FIRST 18 MONTHS: SYSTEMS-BASED CURRICULUM CLERKSHIPS: WORKING TOWARDS INTEGRATED MODEL
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HOW Cognitive Base Teach it Explicitly Forming a Professional Identity
Experiential Learning encourage the active & Reflection process Role Modeling requires knowledge and self-awareness Simulation supplement life experiences The Environment must support professional values
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Teaching Professionalism
Year 1 Year 4 Level of Sophistication Add Social Contract Undergraduate Postgraduate Practice Imparting the Cognitive Base Capacity to Develop Professional Identity Promoting Self-Reflection
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Imparting the Cognitive Base
Teaching Healing Year 1 Year 4 Level of Sophistication Add Physician Wellness Undergraduate Postgraduate Practice Imparting the Cognitive Base Capacity to Internalize Healing Promoting Self-Reflection Boudreau, Cassell & Fuks. Med Ed, 2008
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The Cognitive Base Requires an institutionally accepted definition.
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.
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The Cognitive Base DEFINITIONS
The International Charter Organizations: ABIM/ ACGME/CMA/Royal Colleges Cruess Johnston & Cruess Swick Self-generated: must be based on the literature ALL ARE ACCEPTABLE- PICK ONE ALL INCLUDE THE HEALER ROLE
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The Social Contract PROPOSES RIGHTS, PRIVILEGES, AND OBLIGATIONS ON BOTH SIDES “BARGAIN” Medicine is given prestige, autonomy , the privilege of self-regulation , and rewards on the understanding that it will be altruistic, self-regulate well , be trustworthy, and address the concerns of society
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PROFESSIONAL IDENTITY
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THE NATURAL HISTORY OF PROFESSIONAL IDENTITY
Start of Career Retirement Lay Person Medical Student Resident Physician EVOLVING Maintaining Enhancing Diminishing Generic Physician Discipline- Specific MD Person
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HOW?- SOCIALIZATION “The process by which a person learns to function within a particular society or group by internalizing its values and norms” OED “Involves training for self-image and identity….. melding knowledge and skills with an altered sense of self.” Hafferty, 2009
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The McGill Experience 1997 - 2011 A Work in Progress
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AN INCREMENTAL APPROACH
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UNDERGRADUATE A longitudinal four year program- Physicianship
Distinct approaches to the Healer and the Professional Strong support from Dean, Associate Deans, Chairs Ongoing Faculty Development New resources- MD Director, Senior Administrator, $$ New admission process- McGill MMI Osler Fellows- mentor 6 students for 4 years
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UNDERGRADUATE Incorporation of pre-existing activities including ethics, professionalism Creation of new learning experiences Revision of evaluation system- global rating scale, P-MEX, Faculty Evaluation Form All students required to complete the program Program evaluation underway-baseline established Boudreau, Cruess & Cruess Perspectives in Biol & Med. 2011
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< Content-Whole Class
“Flagship Activities”- at regular intervals- required HEALER & PROFESSIONAL ROLES 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, the Healer, and You”- Prof hours < *Prof st yr Prof nd yr Prof rd yr *were already in place
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Content- Whole Class HEALER ROLE
The personal cost of caring (physician wellness) The doctor/ patient relationship perspectives of both Relating to team members (simulation center) Personal narratives Integrating the healer and professional roles conflicts and context
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Content- Individual Courses
unit specific activities (small group) pre-clinical clinical simulation humanism/narrative medicine films & literature spirituality community service HARDER TO ORGANISE- MORE RANDOM THAN WHOLE CLASS ACTIVITIES
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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 Steinert et al. 2011
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OUTCOME STUDY FOCUS GROUPS- YEARS 1- 4 Pre- Introduction, During, Post
Impressive buy-in Differences between third and fourth year Some differences between classes (?character) Students spontaneously use the vocabulary of Physicianship as they progress through the curriculum Boudreau: underway
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POST GRADUATE Mandatory Half-Day for All R IIs The Cognitive Base
Structured Interactive Lectures McGill & Non-McGill Small Group Sessions Faculty & Senior Residents Co-Facilitate All have attended Faculty Development session on professionalism Vignettes & Small Group Discussion social contract Pre/ Post assessment of knowledge & opinions
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POST GRADUATE 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 reflecting attributes Improving the learning environment faculty development targeting role models Assessment of faculty & resident professionalism
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REALITY Professionalism can be taught well- and hopefully learned- at the undergraduate level, less well at the postgraduate level, and there is continuing difficulty with practicing physicians (CME)
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EVALUATION
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EVALUATION Knowledge of Professionalism MCQ’s, short answers, OSCE’s
Professional Behaviors Behaviors used at all levels derived from attributes
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OBSERVABLE BEHAVIORS USED TO EVALUATE
PROFESSIONALISM AT McGILL Listened actively to patient Showed interest in patient as a person Recognized and met patient needs Extended his/herself to meet patient needs Ensured continuity of patient care Advocated on behalf of a patient Demonstrated awareness of limitations Admitted errors/omissions Solicited feedback Accepted feedback Maintained appropriate boundaries Maintained composure in a difficult situation Maintained appropriate appearance Was on time Completed tasks in a reliable fashion Addressed own gaps in knowledge and skills Was available to colleagues Demonstrated respect for colleagues Avoided derogatory language Maintained patient confidentiality Used health resources appropriately The P-MEX Form & Behaviors Validated Cruess et al Academic Medicine, 2006
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Student Evaluation of Faculty Physicianship at McGill
Based on P-MEX Behaviors Student & Faculty Input Electronic (One- 45) Must be filled out to obtain marks electronically In use since Sept. 1, 2009 Pilot: Todhunter et al, 2011
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Faculty performance (global ratings)
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Resident performance (global ratings)
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USE OF DATA All unacceptable ratings UG Dean
(Comments read immediately) Summary of individual ratings Individual (Comments edited) Program Directors Summary of Data Department Heads (Including Comments) UG/PG Deans
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WHERE ARE WE NOW? 1. An enormous ongoing data bank 2. Psychometric analysis- begun 3. Action has been taken (urgent issues) 4. Is now a part of faculty/resident performance assessment 5. Potential for monitoring intervention R’s: recognition/ reward/ remediation/ removal Target- individual/ unit/ institution 6. May influence role modeling & the hidden/informal curriculum
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Future Actions- McGill
Expand our understanding of identity formation and socialization Use this knowledge to: Reframe the curriculum around professional identity formation Alter the process of socialization to better support identity formation Use student evaluation of faculty to: Improve role modeling Alter the hidden/informal curriculum
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The Healer role is inherently aspirational and is taught as such Professionalism must also be taught as “An Ideal To Be Pursued” rather than as a set of rules and regulations Cruess, Cruess & Johnston. Lancet, 1998
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Centre for Medical Education, McGill University
THANK YOU! Centre for Medical Education, McGill University
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