Comprehensive Approach to Teaching Professionalism in Medicine

1. AN INTGRATED PROGRAM FOR TEACHING MEDICAL PROFESSIONALISMThe McGill Experience1997-2011

2. The Work of Many Individuals

3. 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

4. FLEXNER • Scaled “the cognitive peak” • The next mountain involves “non-cognitive skills, and in particular professionalism” Siu & Reiter 2008

5. PHYSICIANSHIPHealer& ProfessionalDEFINITION andATTRIBUTES TEACHING & LEARNING STUDENTS RESIDENTS FACULTY ADMISSIONCRITERIA EVALUATION STUDENTS RESIDENTS FACULTY

6. PROFESSIONDEFINITION andATTRIBUTES FACULTY DEVELOPMENT!! ADMISSIONCRITERIA TEACHING & LEARNING STUDENTS RESIDENTS FACULTY EVALUATION STUDENTS RESIDENTS FACULTY Steinert et al. Multiple Publications

7. 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 professa commitment to competence, integrity and morality, altruism, and to the promotion of the public goodwithin 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

8. 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

9. Attributes PHYSICIAN Healer Professional 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 Caring/ compassion listen Insight Openness Respect for the healing function Respect patient dignity/autonomy Advocate for Patient Presence/Accompany Professional Healer Based on the Literature

10. Professionalism as the word is used usually includes both rolesMcGill Uses“PHYSICIANSHIP”which includes both

11. ADMISSION PROCESS

12. 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?

13. THE McGILL MMIOBJECTIVES • TO IDENTIFY CANDIDATES WHO ALREADY • DEMONSTRATE THE ATTRIBUTES OF • THE HEALER AND THE PROFESSIONAL • TO PUBLICLY INDICATE THE IMPORTANCE OF THESE ATTRIBUTES

14. 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

15. 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

16. TEACHINGPHYSICIANSHIPThe Healer & The ProfessionalUNDERGRADUATE

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

18. HOW • Cognitive BaseTeach 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

19. TeachingProfessionalism Undergraduate Postgraduate Practice Year 1Year 4 Level of Sophistication Add Social Contract Imparting the Cognitive Base Capacity to Develop Professional Identity Promoting Self-Reflection

20. TeachingHealing Undergraduate Postgraduate Practice Year 1Year 4 Level of Sophistication Add Physician Wellness Imparting the Cognitive Base Capacity to Internalize Healing Promoting Self-Reflection Boudreau, Cassell & Fuks. Med Ed, 2008

21. 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.

22. 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

23. 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

24. PROFESSIONAL IDENTITY

25. THE NATURAL HISTORY OF PROFESSIONAL IDENTITY Professional Identity Start of Career Retirement Lay Person Medical Student Resident Physician EVOLVING Maintaining Enhancing Diminishing Generic Physician Discipline- Specific MD Person

26. 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

27. The McGill Experience 1997 - 2011 A Work in Progress

28. AN INCREMENTAL APPROACH

29. 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

30. 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

31. Content-Whole Class < *Prof 101 - 1st yr Prof 201 - 2nd yr Prof 301 - 3rdyr “Flagship Activities”- at regular intervals- required HEALER & PROFESSIONAL ROLES • lecturessmall 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 *were already in place

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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)

39. EVALUATION

40. EVALUATION • Knowledge of Professionalism MCQ’s, short answers, OSCE’s • Professional Behaviors Behaviors used at all levels derived from attributes

41. OBSERVABLE BEHAVIORS USED TO EVALUATE PROFESSIONALISM AT McGILL The P-MEX Form & Behaviors Validated Cruess et al Academic Medicine, 2006

42. 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

43. Faculty performance (global ratings) 4715 ratings

44. Resident performance (global ratings) 2675 ratings

45. 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

46. WHERE ARE WE NOW? 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

47. 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

48. The Healer role is inherentlyaspirational and is taught as suchProfessionalism must also be taught as “An Ideal To Be Pursued” rather than as a set of rules and regulations Cruess, Cruess & Johnston. Lancet, 1998

49. THANK YOU! Centre for Medical Education, McGill University