Ian Hart

1. Ian Hart “The real role of medical teachers is to promote, encourage, teach and facilitate capability and enthusiasm for self-directed and lifelong learning” “I like to make things happen” OTTAWA CONFERENCE CAME

2. “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

3. Physicians must both understand professionalism (which many do not) and live it every day(which many do)

4. This is Important to Society “Neither economic incentives, nortechnology, nor administrative controlhas proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism” Sullivan, 1995

5. PROFESSIONALISM • Traditionally taught by role models • It remains an essential method • It alone is no longer sufficient • Role models must understand professionalism

6. The Challenge • How to impart knowledge of professionalism to students, residents and faculty. • How to encourage the behaviors characteristic of the good physician.

7. •Effective teaching of professionalism must reach both the head and the heart• This is the preferred learning style of the present generation

8. THE LITERATURE TWO APPROACHES • Teach it explicitly: definitions/list of traits • Teach it as a moral endeavor: altruism/service/role modeling/ experiential learning

9. MUST DO BOTH !Teaching aloneremainstheoreticalExperiential learning aloneselective/disorganized knowledge of professionalism and professional obligations

10. EDUCATIONAL THEORY SITUATED LEARNING (Brown et al, 1989) • OBJECTIVE: transfer knowledge from abstract and theoretical to useful and useable • METHOD: embed learning in authentic activities

11. Before knowledge can be embedded in authentic activities it MUST first be acquired

12. HOW • Cognitive base - teach it explicitly • Self-reflection - encourage the active process • Role modeling - requires knowledge and self-awareness • The environment - must support professional values

13. Teaching Professionalism UndergraduatePostgraduate Year 1 Year 4  Level of Sophistication “social contract” Imparting the Cognitive Base “Professionalism” > > > > > > > > > > > capacity to personalize professionalism Promoting Self-Reflection

14. 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. TELL A STORY

15. Self-Reflection • Definition: purposeful thought provoked by learner’s unease when they recognize that their understanding is incomplete Dewey, 1933 • Requirements: 1. something to reflect on 2. time to reflect and role models 3. motivation Albanese: Medical Education, 2006

16. The Physician Has Two Roles • Healer • Professional • Served simultaneously • Analyzed separately

17. Healing and Professionalism The concept of the healer The concept of the professional Middle ages “Learned professions” clergy, law, medicine 1850:Legislation 1900:University linkage The Present Antiquity Hippocrates technology “curing” The Present Code of Ethics Science

18. Attributes Competence Commitment Confidentiality Altruism Integrity / Honesty codes of ethics Morality / Ethical Behavior Responsibility to the profession Autonomy Self-regulation associations institutions Responsibility to society Team work Caring/ compassion Insight Openness Respect for the healing function Respect patient dignity/ autonomy Presence Professional Healer

19. The Primary Role is that of the Healer

20. Professionalism as the word is used generally includes both roleswe use “PHYSICIANSHIP”

21. 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, 1985

22. DefinitionProfession “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 (1985) and the literature on professionalism Cruess, Johnston, Cruess “Teaching and Learning in Medicine”, 2004

23. The social contract in health care hinges on professionalism. • It serves as the basis for the expectations of medicine and society.

24. “The rights and duties of the state and its citizens are reciprocal and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract” Gough: “The Social Contract”, 1957

25. The Social Contract A mix of: •the explicit and the implicit • the written and the unwritten - licensing laws, health care legislation, codes of ethics, the Charter • legal and moral obligations • the universal and the local Constantly evolving (being renegotiated)

26. Society’s Expectations of Medicine to fulfill the role of the healer assured competence altruistic service morality / integrity / honesty codes of ethics accountability transparency source of objective advice promotion of the public good Medicine’s Expectations of Society trust autonomy self-regulation health care system value-laden adequately funded role in public policy patients accept responsibility for health monopoly rewards –non-financial • respect • status – financial The Social Contract Individual and Collective Responsibilities

27. The McGill Experience1997 - 2006A Work in ProgressThe result of the Efforts of Many Individual Faculty Members

28. GENERAL PRINCIPALS • Integrated approach throughout undergraduate and postgraduate education. • Activities throughout the curriculum • Support of Dean’s office & Chairs • Multiple techniques of teaching. • Formal Teaching • small groups • independent activities • role models -faculty - residents • Self-Reflection • Evaluation linked to teachingCruess & Cruess • Faculty Development EssentialMedical Teacher,2006

29. Faculty Development Results • 4 sessions on teaching or evaluating professionalism over 3 years • 152 faculty members attended at least one half day session. • Agreed on the cognitive base and behaviors reflecting professionalism. • Developed methods of formal instruction/experiential learning • Participants becameskilled group leaders/trained role models. • Led to curricular change. • ? Altered the environment. Steinert, Cruess, Cruess and Snell Medical Education, 2005

30. Undergraduate- NEW • A longitudinal 4 year program on Physicianship • Distinct approaches to the Healer and the Professional. • Redefinition of the clinical method • Incorporation of existing activities including ethics. • Creation of new learning experiences. • Revision of evaluation system - global rating scale - P-MEX • All students required to complete the program. • Consultants: Eric Cassell, Rita Charon

31. Content-Whole Class < Prof 101 - 1st yr Prof 201 - 2nd yr Prof 301 – 3rd year “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

32. Content- Individual Courses • unit specific activities (small group) pre-clinical clinical • humanism/narrative medicine • spirituality • community service

33. OSLER SCHOLARS • 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” • Salaried

34. PROGRAM EVALUATION • Too early- only 10 years! • faculty 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

35. “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 Medicine In “Aequanimitas”