Transcript Teaching and Evaluating Physicianship

Teaching and Evaluating
Physicianship
The Healer
The Professional
Work in Progress
• What we have accomplished
• Our hopes for the future
What is Physicianship?
The Physician Has Two Roles
• Healer
• Professional
The two roles
•Served simultaneously.
•Analyzed separately.
Professionalism and Medicine
The concept of the healer
The concept of the professional
Antiquity
Middle ages
“Learned professions”
clergy, law, medicine
Hippocrates
technology
“curing”
The Present
Code of
Ethics
Science
1850: Legislation
1900: University linkage
The Present
Medicine’s Values Are
Derived From Both The
Healer and the Professional
The Primary Role is that
of the Healer
Society uses the concept of the
professional as a means of
organizing the delivery of complex
services which it requires,
including that of the healer.
“The Professional Model”
Other Models are Available
• Bureaucratic
• Free Market
>
none pure
Neither Share the Values of the Healer
The Social Contract
Society
Medicine
•
fulfill the role of the healer
• guaranteed competence
• altruistic service
• morality and integrity
• promotion of the public
good
• openness
• accountability
•
•
•
•
•
•
monopoly
autonomy
trust and respect
self-regulation
adequate resources
status and rewards
TRUST


financial
non-financial
• The social contract in health care
hinges on professionalism.
• It serves as the basis for the
expectations of both medicine
and society.
• To preserve values in changing times,
Physicians must understand the linked
roles of the healer and the professional.
• They must be taught.
To Heal
To make whole or sound in bodily
conditions; to free from disease or ailment,
to restore to health or soundness.
Oxford English Dictionary
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 and to
society.”
Derived from the Oxford English
Dictionary and the Literature on Professionalism
In Press, “Teaching and Learning in Medicine”
Physician
Healer
Caring and compassion
Insight
Openness
Respect for the
healing function
Respect patient
dignity and
autonomy
Presence
Professional
Competence
Commitment
Confidentiality
Altruism
Integrity and honesty
Morality and ethics
Responsibility to the
profession
Autonomy
Self-regulation
Responsibility
to society
Team work
• Each attribute will be reflected (or not)
by appropriate (or inappropriate)
behavior.
• These behaviors can be observed and
evaluated.
The Challenge
• How to impart knowledge of
Physicianship to students and residents.
• How to encourage behavior
characteristic of the good physician.
By concentrating on the role of
the Professional we risk
neglecting that of the Healer in spite of overlap
THEY ARE DIFFERENT
General Principles
• Integrated approach throughout faculty for
undergraduate and postgraduate education.
• Support of Dean’s Office and Chairs.
• Multiple techniques of teaching.
» The International Charter
» formal teaching
» small groups
» independent activities
» role models - attendings
- residents
» other
General Principles
• Evaluate what is taught.
The International Charter
• Faculty and Resident development
essential.
Faculty Development
1) Teaching Professionalism - think tank (20)
2) Teaching Professionalism: Dean’s Invitation (40)
3) Evaluating Professionalism - think tank (20)
4) Evaluating Physicianship - (90)
Behaviors Identified
150 Faculty members and residents have participated.
Large pool of trained teachers and role models.
McGill: 1996 - 2003
• Body Donor Service:
• Prof 101 followed by small groups:
• Elective: The Profession and Society:
1992
1997
1999
20 students
• White Coat Ceremony:
2000
Pledge
• Mandatory half day on professionalism
for all residents (CanMeds)
• Professionalism 101 to incoming students
201 to 1st year students
2000
2003
2004
Assessment:
• episodic
• ineffective
evaluation • methods primitive
• ineffective
the role of the healer not
addressed explicitly.
teaching
Program on Physicianship
• to teach the role of the Healer and The
Professional.
• to promote behaviors characteristic of both.
• to evaluate knowledge of both roles
• to evaluate behaviors characteristic of both.
Four Committees
The Healer
The Professional
Evaluation
Post Graduate Education
Recommendations
Undergraduate
• A longitudinal program on physicianship throughout 4
years of medical school.
• Distinct approaches to the Healer and the Professional.
• Incorporate existing activities including ethics.
• Create new learning experiences.
• Revise evaluation system - global rating scale
- miniCEX
• All students must successfully complete program.
Recommendations
Postgraduate
• All residents must master the cognitive base of
professionalism.
• Self reflection must be promoted
- small groups
- ? portfolios
• revise evaluation system
- global rating scale
- miniCEX
Unit 1
Unit 2
Unit 3
September
Molecules,
Cells &
Tissues
October
November
Gas, Fluids & Electrolytes
(4 wks)
(9 wks)
Basis of Medicine & Dentistry (BOM)
Unit 5
Unit 6
Unit 7
Unit 4
December
Life Cycle
January
February
Endocrinology,
Metabolism & Nutrition
(3 wks)
March
Musculoskeletal &
Blood
April
May
Nervous System & Special
Senses
(4 wks)
(8 wks)
(7 wks)
June
Host
Defense &
Host
Parasite
(5 wks)
July
August
Vacation/Research
ITP
1
*
2
*
PHYSICIANSHIP
*
*
*
3
Introduction to Clinical Medicine (ICM)
Unit 8
September
Host
Defense &
Host
Parasite
(2 wks)
Unit 9
October
November
Pathobiology, Treatment &
Prevention of Disease
December
January
Professional
Skills:
ICS
Ethics & Law
EBM
(14 wks)
February
March
Intro to Internal
Medicine
(4 wks)
ITPM
*
*
(7 wks)
*
4
5
April
May
June
Intro to Surgery/
W Intro to
Anesthesia/
C Emergency
Radiology/Ophthalmology T Med/
Neurology/
Oncology
Family Medicine
(7 wks)
(7 wks)
*
PHYSICIANSHIP
July
August
Elective
#1
Vacation /
Research
(4 wks)
*
Practice of Medicine (POM) Clerkship
September
Intro to
Psychiatry/
Pediatrics/
Ob & Gyn/
Hosp Pract
(4 wk)
October
*
November
December
Pediatrics
Obstetrics &
Gynecology
(8 wks)
(8 wks)
*
*
January
February
March
Surgery
Psychiatry
(8 wks)
*
PHYSICIANSHIP
April
(8 wks)
*
6
May
June
July
August
Internal Medicine
Elective
#2
Geriatric
Medicine
(8 wks)
(4 wks)
(4 wks)
*
*
Back to Basics (BTB)
September
October
November
December
January
February
Family
Medicine
Elective
#3
Vacation
Elective
#4
Seminar
Option
(Humanities)
Medicine &
Society
(4 wks)
(4 wks)
(4 wks)
(4 wks)
(3 wks)
(4 wks)
*
7
PHYSICIANSHIP
March
April
Seminar Options (3)
(Basic Sciences)
Communication Plus
(3 wks)
(3 wks)
(3 wks)
1 = Lecture and small groups to incoming students
2 = Introduction to the cadaver
3 = Body Donor Ceremony
4 = White Coat Ceremony
5 = Lecture and small groups prior to clerkship
6 = Whole class activity to be developed
7 = Seminars on Professionalism in Society
= ethics lectures and small group in ITP and
second year plus unit specific teaching of ethics
* = unit specific teaching of physicianship
Content
• Whole class (Flagship) activities at regular intervals
– Lectures
small groups
– ethics
small groups
– introduction to the cadaver
small
groups
– body donor service
– white coat ceremony
– 4th year seminars
Content
• unit specific activities (small group)
pre-clinical
clinical
• humanism/narrative medicine
• spirituality
• palliative care medicine
• community service
• portfolio (self-reflection, self-assessment)
Evaluation
• longitudinal - 4 years
• multiple methods
–
–
–
–
–
knowledge - mcq etc. - (do often)
global rating scale - UCSF, Maastrict
critical incidents
portfolio
? MiniCEX
ALL ATTRIBUTES MUST BE EVALUATED
USING AT LEAST ONE METHOD
Faculty Development
– essential - includes residents
– knowledge
role modeling
– evaluation
Requires resources
Resources
Assoc/Assist Dean for Physicianship
Infrastructure
Support - financial and other
Summary
• The role of the Healer and the Professional must
be taught.
• Must start with agreed-upon definitions.
• The teaching of physicianship should represent a
major commitment of the faculty.
• It should be taught and evaluated in a planned
way throughout the curriculum.
“The most important problem
for the future of professionalism is
neither economic nor structural but
cultural and ideological. The most
important problem is its soul”
Freidson, 2001