AN INTGRATED PROGRAM FOR TEACHING MEDICAL

PROFESSIONALISM

The McGill Experience1997-2011

The Work of Many Individuals

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

FLEXNER

• Scaled “the cognitive peak”• The next mountain involves “non-

cognitive skills, and in particular professionalism”

Siu & Reiter 2008

PHYSICIANSHIPHealer& Professional

DEFINITION andATTRIBUTES

ADMISSIONCRITERIA

TEACHING &LEARNING

STUDENTSRESIDENTSFACULTY

EVALUATIONSTUDENTSRESIDENTSFACULTY

PROFESSIONDEFINITION and

ATTRIBUTES

ADMISSIONCRITERIA

TEACHING &LEARNING

STUDENTSRESIDENTSFACULTY

EVALUATIONSTUDENTSRESIDENTSFACULTY

FACULTY DEVELOPMENT!!

Steinert et al. Multiple Publications

DEFINITION: PROFESSION 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

Definition: Healer

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

CompetenceCommitmentConfidentialityAltruismTrustworthy

Integrity / Honesty

codes of ethicsMorality / Ethical BehaviorResponsibility to profession

Autonomy

Self-regulation

associations

institutions

Responsibility to society

Team work

Caring/ compassion listen

Insight

OpennessRespect for the healing functionRespect patient dignity/autonomyAdvocate for Patient

Presence/Accompany

Based on the Literature

PHYSICIAN

Healer Professional

Professionalism as the word is used usually includes both roles

McGill Uses “PHYSICIANSHIP”which includes both

ADMISSION PROCESS

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?

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

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

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

TEACHINGPHYSICIANSHIP

The Healer & The Professional

UNDERGRADUATE

BACKGROUNDMcGill

FIRST 18 MONTHS: SYSTEMS-BASED CURRICULUM

CLERKSHIPS: WORKING TOWARDS INTEGRATED MODEL

• 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

HOW

Year 1 Year 4

Level of Sophistication

Add Social Contract

Teaching Professionalism

Imparting the Cognitive

Base

Promoting Self-Reflection

Capacity to Develop

Professional Identity

Undergraduate PracticePostgraduate

Year 1 Year 4

Level of Sophistication

Add Physician Wellness

Teaching Healing

Imparting the Cognitive

Base

Promoting

Self-Reflection

Capacity toInternalize

Healing

Undergraduate PracticePostgraduate

Boudreau, Cassell & Fuks. Med Ed, 2008

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.

The Cognitive BaseDEFINITIONS

• 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

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

PROFESSIONAL IDENTITY

THE NATURAL HISTORY OF PROFESSIONAL IDENTITY

Person

Medical Student

Resident Physician

Start of Career Retirement

Professional Identity

Generic Physician

Discipline-Specific MD

EVOLVINGMaintainingEnhancingDiminishing

Lay Person

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

The McGill Experience 1997 - 2011 A Work in Progress

AN INCREMENTAL APPROACH

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

»

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 & CruessPerspectives in Biol & Med. 2011

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 401- 6 hours

*Prof 101 - 1st yr Prof 201 - 2nd yr Prof 301 - 3rd yr<

*were already in place

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

Content- Individual Courses

• unit specific activities (small group) pre-clinical

clinical• simulation• humanism/narrative medicine• films & literature • spirituality• community service

HARDER TO ORGANISE- MORE RANDOMTHAN WHOLE CLASS ACTIVITIES

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

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

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

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

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)

EVALUATION

EVALUATION

• Knowledge of Professionalism MCQ’s, short answers, OSCE’s• Professional Behaviors Behaviors used at all levels

derived from attributes

The P-MEXForm &

BehaviorsValidated

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 appropriatelyCruess et alAcademic Medicine, 2006

OBSERVABLE BEHAVIORS USED TO EVALUATE PROFESSIONALISM AT McGILL

Student Evaluation of FacultyPhysicianship 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

Faculty performance (global ratings)

4715 ratingsUnsatisfactory Fair Good Very Good Excellent

0

500

1000

1500

2000

2500

Fre

qu

ency

n = 43

Resident performance (global ratings)

Unsatisfactory Fair Good Very Good Excellent0

200

400

600

800

1000

1200

1400

Fre

qu

ency

n = 23

2675 ratings

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

•

1. An enormous ongoing data bank2. Psychometric analysis- begun 3. Action has been taken (urgent issues)4. Is now a part of faculty/resident performance assessment5. Potential for monitoring intervention- 4 R’s: recognition/ reward/ remediation/

removal Target- individual/ unit/ institution 6. May influence role modeling & the hidden/informal curriculum

WHERE ARE WE NOW?

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

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

THANK YOU!

Centre for Medical Education, McGill University