AN INTGRATED PROGRAM FOR TEACHING MEDICAL PROFESSIONALISM The McGill Experience 1997-2011

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

PHYSICIANSHIP

Healer& Professional DEFINITION and ATTRIBUTES

ADMISSION CRITERIA TEACHING & LEARNING STUDENTS RESIDENTS FACULTY EVALUATION STUDENTS RESIDENTS FACULTY

PROFESSION

DEFINITION and ATTRIBUTES

FACULTY DEVELOPMENT!!

ADMISSION CRITERIA TEACHING & LEARNING STUDENTS RESIDENTS FACULTY EVALUATION STUDENTS RESIDENTS FACULTY Steinert et al. Multiple Publications

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 practice and the privilege of self-regulation.

members are accountable society.” autonomy Professions and their to those served, to their colleagues, and to in • Derived from the Oxford English Dictionary and the literature on professionalism • Cruess, Johnston, Cruess “Teaching and Learning in Medicine”, 2004

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

PHYSICIAN

Healer Professional Caring/ compassion listen Insight Openness Respect for the healing function Respect patient dignity/autonomy Advocate for Patient Presence/Accompany

Competence

Commitment Confidentiality Altruism Trustworthy Integrity / Honesty codes of ethics Morality / Ethical Behavior Responsibility to profession Autonomy Self-regulation associations institutions Responsibility to society Team work Based on the Literature

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

TEACHING PHYSICIANSHIP The Healer & The Professional UNDERGRADUATE

BACKGROUND McGill

FIRST 18 MONTHS: SYSTEMS-BASED CURRICULUM CLERKSHIPS: WORKING TOWARDS INTEGRATED MODEL

HOW

• •

Cognitive Base

Role Modeling

Teach it Explicitly Forming a Professional Identity

Experiential Learning & Reflection encourage the active process Simulation The Environment requires knowledge and self-awareness supplement life experiences must support professional values

Teaching Professionalism

Undergraduate

Year 1 Year 4

Postgraduate Practice Imparting the Cognitive Base

Level of Sophistication Add Social Contract

Promoting Self-Reflection

Capacity to Develop Professional Identity

Imparting the Cognitive Base

Teaching Healing

Undergraduate

Year 1 Year 4

Postgraduate Practice

Level of Sophistication Add Physician Wellness

Promoting Self-Reflection

Capacity to Internalize Healing 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 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

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

Start of Career Lay Person Person

Professional Identity

Medical Student Generic Physician Retirement Resident Discipline Specific MD Physician EVOLVING Maintaining Enhancing Diminishing

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 & Cruess Perspectives in Biol & Med.

2011

Content-Whole Class

“Flagship Activities”-

at regular intervals- required * Prof 101 - 1st yr

HEALER & PROFESSIONAL ROLES

– lectures small groups < * ethics small groups – Prof 201 - 2nd yr Prof 301 - 3 rd yr – – – – – – 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 * 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 RANDOM THAN 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:

communication skills, risk management, teamwork, resident wellness ethics, malpractice,

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

OBSERVABLE BEHAVIORS USED TO EVALUATE PROFESSIONALISM AT McGILL

The P-MEX Form & Behaviors Validated Cruess et al Academic Medicine, 2006 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

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

Faculty performance (global ratings) 2500 2000 1500 1000 500 n = 43 0 Unsatisfactory Fair Good Very Good Excellent 4715 ratings

Resident performance (global ratings) 1400 1200 1000 800 600 400 200 0 n = 23 Unsatisfactory Fair Good Very Good Excellent 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

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 4 R’s: recognition/ reward/ remediation/ removal Target- individual/ unit/ institution 6. May influence role modeling & the hidden/informal curriculum

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