IMPLEMENTING PROFESSIONALISM IMPLEMENTING PROFESSIONALISM TEACHING & ASSESSMENTTEACHING & ASSESSMENT

General PrinciplesGeneral Principles

Richard Cruess OC, MD, FRCSCRichard Cruess OC, MD, FRCSCSylvia Cruess MD, CPSQSylvia Cruess MD, CPSQ

McGill UniversityMcGill 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.26 2005

Physicians must both understand professionalism (which many do not)

and live it every day(which many do)

PROFESSIONALISMPROFESSIONALISM

• Traditionally taught by role models

• It remains an essential method

• It alone is no longer sufficient

• Role models must understand professionalism

THE CHALLENGETHE 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 LITERATURETHE 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

HOWHOW

• 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 LEARNERLEVEL OF LEARNER

Imparting core knowledge

Promoting self-reflection, application

level of

sophistication

Medical student Residency

Preclinical Clinical

capacity to personalize

Increasing complexity

Increasing reflection

SOCIAL CONTRACTSOCIAL CONTRACT

OVERALL APPROACHOVERALL 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 PRINCIPLESGENERAL PRINCIPLES

1. INSTITUTIONAL SUPPORT

• Support of Dean’s office & Chairs• Time in Curriculum- modest• $$$$ and Human Resources

GENERAL PRINCIPLESGENERAL PRINCIPLES

2. ALLOCATION OF RESPONSIBILITY

• Leader/Champion- respected individual• Committee- broad representation

PROFESSIONALISM CROSSES DEPARTMENTAL LINES

WHAT WILL BE YOUR ROLE?

GENERAL PRINCIPLESGENERAL 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 PRINCIPLESGENERAL PRINCIPLES

4. THE COGNITIVE BASE

• Choose a definition• Teach it explicitly and often with increasing levels

of sophistication• DON’T CHERRY PICK

GENERAL PRINCIPLESGENERAL PRINCIPLES

5. EXPERIENTIAL LEARNING & SELF-REFLECTION

• “Professional identity arises from a long-term combination of experience and reflection on experience”

-Hilton & Slotnick, 2005

GENERAL PRINCIPLESGENERAL 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 developmentrole models must understand

professionalism• Support it• Reward it• Assess it- with consequences (+&-)

GENERAL PRINCIPLESGENERAL PRINCIPLES

7. FACULTY DEVELOPMENT

• Affects : knowledge & skill base

environment

role models• Can promote change

GENERAL PRINCIPLESGENERAL PRINCIPLES

8. CONTINUITY

• Admissions• Undergraduate• Post graduate • Continuing professional development

PROFESSIONALISM DOES NOT CHANGE

Teach in each yearTeach in each yearStage-appropriateStage-appropriate

GENERAL PRINCIPLESGENERAL PRINCIPLES

9. EVALUATION

Knowledge/Behaviors Formative/Summative• Students• Residents• Faculty- informal & hidden curriculum• Program- is it working?

obligationobligation to societyto society

GENERAL PRINCIPLESGENERAL 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 PRINCIPLESGENERAL PRINCIPLES

The McGill Experience1997 – 2008

A Work in Progress

The Result of the Efforts of Many Individual Faculty Members

UNDERGRADUATE - NEWUNDERGRADUATE - 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 - NEWUNDERGRADUATE - NEW

CONTENT – WHOLE CLASSCONTENT – 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 401- 6 hours

**Prof 101 - 1st yrProf 101 - 1st yrProf 201 - 2nd yrProf 201 - 2nd yrProf 301 – 3Prof 301 – 3rdrd year year<<

*were already in place

CONTENT – INDIVIDUAL CONTENT – INDIVIDUAL COURSESCOURSES

• unit specific activities (small group)

pre-clinicalclinical

• humanism/narrative medicine• spirituality• community service

OSLER FELLOWSOSLER 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- CanMEDSPOST GRADUATE- CanMEDS

Occurred Against the Backdrop of the Undergraduate Program

• Mandatory Half-Day on Professionalism for Each RIISeparate structured interactive lecture- THE COGNITIVEBASE- for McGill and non-McGill graduates followed by

Combined small-group session using vignettes and discussion of the

social contractFaculty member and senior resident co-facilitate each groupEach has attended a faculty development workshopPre/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 - CANMEDSPOST GRADUATE - CANMEDS

PROGRAM EVALUATIONPROGRAM 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 MedicineIn “Aequanimitas”