Seeking Equanimity: Sir William Osler

and Competence by Design

Sharon E Card Canadian Society of Internal Medicine October 2016 Sharon.card@usask.ca @sharon_cards

Learning Outcomes 1. Describe the Royal College

of Physician and Surgeon’s Competence by Design (CBD) initiative.

2. List the ways that the CBD initiative will impact General Internal Medicine (GIM) postgraduate training.

3. Compare and contrast the future of GIM education with postgraduate training in the time of Sir William Osler.

Source of Images – Osler Library

Canadian Society of Internal Medicine Annual Meeting 2016

Montreal, QC

Sharon E. Card. Osler Lecture

The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational purposes, and should not replace other sources

of information or your medical judgment.

What is Competence by Design (CBD)?

• “The CBD initiative will transition specialist medical education from a traditional time-based model to a hybrid form of competency-based medical education (CBME). CBD is a multi-year transformational change initiative”.

• RCPSC Website - http://www.royalcollege.ca/rcsite/cbd/competence-by-design-cbd-e

Why Change?2,3

“that the direction in which education starts a man will determine his future life.” Plato, Republic, iv. Jowett’s translation. As quoted by Osler in Aequanimitas Page 22.

Pillars of CBD*

1. Clear articulation of Graduates Outcomes 2. Deliberate Entrustment 3. Learning in Authentic Environments 4. Facilitated Learner Continuous Improvement 5. Program of Assessment * According to S. Card.

One - Clear Articulation of Graduates Outcomes.

“Competency-based Medical Education is an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs.” Frank et al. 4

Building a General Internist5-9

GIM Approach = Foundation Patient not organ centered Optimize not maximize care Holistic and Comprehensive Evidence (intelligence) informed Anticipate and Coordinate Collaborative Practice Adapt to context Life Long Learner

Acute and Critical Illness Common Emergent Multisystem Undifferentiated Autonomous AND Safe With Stressors

Pregnancy & Surgery

Chronic Illness Preventive Care Single or Multiple Competing priorities Uncertainty Ambiguity

Roof = Adapted to Context

System Skills Team Skills 21st Century Patient Societal Expectations Information Technology Leadership

Diversity of Contexts

“on the absence of the sense of responsibility which permitted a criminal laxity in medical education unknown before in our annals.” Sir William Osler2

Two – Deliberate Entrustment10

Entrustable Professional Activity (EPA)10

Not Assessed

Does Not Meet

Meets Exceeds

MEDICAL EXPERT Knowledge of Anatomy

COMMUNICATOR Informed Consent

COLLABORATOR Collaborates with nurses

ADVOCATE Uses procedure wisely

PROFESSIONAL Knows limits

• I entrust this resident to perform ABGs unsupervised. Yes No

“One of the chief reasons for this uncertainty is the increasing variability in the manifestations of any one disease”. Sir William Osler. 2

13

Undoing the Pixelation of Medical Education.

Three – Learning in Authentic Environments.

• “Ask any physician of twenty years’ standing how he has become proficient in his art, and he will reply, by constant contact with disease; and he will add that the medicine he learned in the schools was totally different from the medicine he learned at the bedside.”

• “the best teaching is that

taught by the patient himself.”

• Sir William Osler. 2

Source of Images – Osler Library

What is “Service”?

• “contribution to the welfare of others”

• Merriam Webster Dictionary

• Service demands must not interfere with the ability of the residents to follow the academic program.

• RCPSC “B” Accreditation Standards.

• “I desire no other epitaph – no hurry about it, I may say – than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.”

• Sir William Osler2

Four – Facilitated Learner Continuous Improvement11-16

Sir William Osler2

Educational Alliance 11-16

“More perhaps than any other professional man, the doctor has a curious – shall I say morbid? – sensitiveness to (what he regards) personal error. In a way this is right; but it is too often accompanied by a cocksureness of opinion which, if encouraged, leads him to so lively a conceit that the mere suggestion of mistake under any circumstances is regarded as a reflection on his honour, a reflection equally resented whether of lay or of professional origin. Sir William Osler2

Start out with the conviction that absolute truth is hard to reach in matters relating to our fellow creatures, healthy or diseased, that slips in observation are inevitable even with the best trained faculties, that errors in judgment must occur in the practice of an art which consists largely of balancing probabilities; - start, I say, with this attitude in mind, and mistakes will be acknowledged and regretted but instead of a slow process of self-deception, with ever increasing inability to recognize truth, you will draw from your errors the very lessons which may enable you to avoid their repetition.” Sir William Osler2

Five – Program of Assessment. “To cover the vast field of medicine in four years is an impossible task. We can only instil principles, put the student in the right path, give him methods, teach him how to study, and early to discern between essentials and non-essentials”. “Perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offence in the pathway of the true student”. Sir William Osler2

Source of Images – Osler Library

Program of Assessment • “and the degree could be

safely conferred upon certificates of competency, which would really mean a more thorough knowledge of a man’s fitness than can possibly be got by our present system of examination.”

• Sir William Osler2

Source of Images – Osler Library

Why Change?

1. Clear articulation of Graduates Outcomes

2. Deliberate Entrustment 3. Learning in Authentic

Environments 4. Facilitated Learner

Continuous Improvement

5. Program of Assessment

1. Meet societal needs. 2. Focus training on tasks 3. Back to the bedside –

one’s future career. 4. Educational Alliance. 5. Avoid high stakes exams

as main measurement of attainment of competency.

McGill University Faculty of Medicine at its Semicentennial, 1882 Standing, from left to right, are Thomas G. Roddick, George Ross, William E. Scott, William Osler, Francis J. Shepherd, William Gardner, George W. Campbell, Gilbert Prout Girdwood, Frank Buller, and Richard L. MacDonell. Sitting, from left to right, are Robert Palmer Howard, William Wright, John William Dawson, Duncan C. MacCallum, Robert Craik, and George E. Fenwick.

Source of Images – Osler Library

Era of General Internal Medicine

• Leaders in: Adaptability Relationships Systems Engineering Education Patient Safety Complex Care Wellness, Resilience And More…

Source of Images – Osler Library

Building a General Internist5-9

GIM Approach = Foundation Patient not organ centered Optimize not maximize care Holistic and Comprehensive Evidence (intelligence) informed Anticipate and Coordinate Collaborative Practice Adapt to context Life Long Learner

Acute and Critical Illness Common Emergent Multisystem Undifferentiated Autonomous AND Safe With Stressors

Pregnancy & Surgery

Chronic Illness Preventive Care Single or Multiple Competing priorities Uncertainty Ambiguity

Roof = Designed for Complexity Trained for individual competency AND able to practice and lead collectively

Aequanimitas2

“Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.”

“In a true and perfect form, imperturbability is indissolubly associated with wide experience and intimate knowledge of the varied aspects of disease.”

William Osler's Carte de Visite, October, 1881

Source of Images – Osler Library

Quoting Oceanus Sir William Osler2

Thanks to:

Dr. Robert T. Card for lending me his copy of Aequanimitas given on his graduation in 1964.

Niklos and Scott. The Sir William Osler Library for permission to

reproduce the pictures in this talk. https://www.mcgill.ca/library/branches/osler

Canadian Society of Internal Medicine. A multitude of people in this room that are true

physicians dedicated to improving their patients’ care current and future.

References: 1. Royal College Website - http://www.royalcollege.ca/rcsite/cbd/competence-by-design-cbd-e. 2. Aequanimatas. Sir William Osler McGraw Hill. 1907. 3. Asch DA, Nicholson S, Srinivas SK, Herrin J, Epstein AJ. How Do You Deliver a Good Obstetrician? Outcome-Based Evaluation of Medical

Education. Acad Med. 2014 89(1): 24-26. 4. Frank JR, Mungroo R, Ahmad Y, et al.Toward a definition of competency-based education in medicine: A systematic review of published

definitions. Med Teach. 2010;32:631–637. 5. Card SE, Snell L, O’Brien B. Are Canadian General Internal Medicine training program graduates well prepared for their future careers?

BMC Medical Education 2006; 6: 56. Pages 1 – 9 6. Card SE, PausJenssen AM, Ottenbreit RC. Determining specific competencies for General Internal Medicine residents (PGY 4 and PGY 5).

What are they and are programs currently teaching them? A survey of practicing General Internists. 7. Card SE, Ward HA, Broberg L. Preparing General Internal Medicine Residents for the Future – Aiming to Match Training to Need – A

Pilot Study in Saskatchewan. CJGIM 2016 11(2): 26 – 30. 8. Card SE, Kassam N. The Future is Bright for Competency-based Education in General Internal Medicine CJGIM 2016 11(1): 25 – 29. 9. The current Royal College documents (objectives of training, specialty training requirements and specific standards of accreditation for

Internal Medicine and General Internal Medicine) can be accessed at: http://www.royalcollege.ca/portal/page/portal/rc/public. 10. Ten Cate, Scheele F. Viewpoint: Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical

Practice? Acad Med. 2007; 82:542–547. 11. Ross S, Dudek N, Halman S, Humphrey-Murto. Context, time, and building relationships: bringing in situ feedback into the conversation.

Med Ed 2016; 50: 889-895. 12. Voyer S et al. Investigating conditions for meaningful feedback in the context of an evidence-based feedback programme. Med Ed.

2016; 50: 943-954. 13. Hauer KE. Evaluating the value of direct observation for learning: the limits of autonomy. Med Ed. 2016; 50: 992-996. 14. Watling C, LaDonna KA, Lingard L, Voyer S ,Hatala R. “Sometimes the work just needs to be done”: socio-cultural influences on direct

observation in medical training. Med Ed 2016; 50: 1054-1064. 15. Watling C, Driessen E, Van Der Vleuten CPM et al. Beyond individualism: professional culture and its influence on feedback. Med Ed

2013; 47: 585-594. 16. Watling C, Driessen E, Van der Vleuten CPM et al. Music lessons: revealing medicine’s learning culture through a comparison with that

of music. Med Ed. 2013; 47: 842-850. 17. Hubinette MM, Regehr G, Cristancho. Lessons from Rocket Science: Reframing the Concept of the Physician Health Advocate. Acad.

Med. 2016; 91: 1344-1347. 18. Holmboe ES and Batalden P. Achieving the Desired Transformation:Thoughts on Next Steps for Outcomes-Based Medical Education.

Acad Med. 2015;90:1215–1223.