AN INTGRATED PROGRAM FOR TEACHING MEDICAL PROFESSIONALISM The McGill Experience 1997-2011
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AN INTGRATED PROGRAM FOR TEACHING MEDICAL
PROFESSIONALISM
The McGill Experience1997-2011
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The Work of Many Individuals
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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
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FLEXNER
• Scaled “the cognitive peak”• The next mountain involves “non-
cognitive skills, and in particular professionalism”
Siu & Reiter 2008
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PHYSICIANSHIPHealer& Professional
DEFINITION andATTRIBUTES
ADMISSIONCRITERIA
TEACHING &LEARNING
STUDENTSRESIDENTSFACULTY
EVALUATIONSTUDENTSRESIDENTSFACULTY
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PROFESSIONDEFINITION and
ATTRIBUTES
ADMISSIONCRITERIA
TEACHING &LEARNING
STUDENTSRESIDENTSFACULTY
EVALUATIONSTUDENTSRESIDENTSFACULTY
FACULTY DEVELOPMENT!!
Steinert et al. Multiple Publications
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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, 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
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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
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CompetenceCommitmentConfidentialityAltruismTrustworthyIntegrity / Honesty codes of ethicsMorality / Ethical BehaviorResponsibility to profession
Autonomy Self-regulation associations institutionsResponsibility to societyTeam work
Caring/ compassion listenInsightOpennessRespect for the healing functionRespect patient dignity/autonomyAdvocate for PatientPresence/Accompany
Based on the Literature
PHYSICIANHealer Professional
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Professionalism as the word is used usually includes both roles
McGill Uses “PHYSICIANSHIP”which includes both
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ADMISSION PROCESS
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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?
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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
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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
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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
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TEACHINGPHYSICIANSHIP
The Healer & The Professional
UNDERGRADUATE
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BACKGROUNDMcGill
FIRST 18 MONTHS: SYSTEMS-BASED CURRICULUM
CLERKSHIPS: WORKING TOWARDS INTEGRATED MODEL
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• Cognitive Base Teach 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
HOW
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Year 1 Year 4
Level of Sophistication
Add Social Contract
Teaching Professionalism
Imparting the Cognitive
Base
Promoting Self-Reflection
Capacity to Develop
Professional Identity
Undergraduate PracticePostgraduate
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Year 1 Year 4
Level of Sophistication
Add Physician Wellness
Teaching Healing
Imparting the Cognitive
Base
Promoting
Self-Reflection
Capacity toInternalize
Healing
Undergraduate PracticePostgraduate
Boudreau, Cassell & Fuks. Med Ed, 2008
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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.
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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
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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
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PROFESSIONAL IDENTITY
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THE NATURAL HISTORY OF PROFESSIONAL IDENTITY
Person
Medical Student
Resident Physician
Start of Career Retirement
Professional Identity
Generic Physician
Discipline-Specific MD
EVOLVINGMaintainingEnhancingDiminishing
Lay Person
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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
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The McGill Experience 1997 - 2011 A Work in Progress
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AN INCREMENTAL APPROACH
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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
»
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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 & CruessPerspectives in Biol & Med. 2011
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Content-Whole Class “Flagship Activities”- at regular intervals- required HEALER & PROFESSIONAL ROLES
– 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, the
Healer, and You”- Prof 401- 6 hours
*Prof 101 - 1st yr Prof 201 - 2nd yr Prof 301 - 3rd yr<
*were already in place
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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
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Content- Individual Courses
• unit specific activities (small group) pre-clinical
clinical• simulation• humanism/narrative medicine• films & literature • spirituality• community service
HARDER TO ORGANISE- MORE RANDOMTHAN WHOLE CLASS ACTIVITIES
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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
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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
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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
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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
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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)
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EVALUATION
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EVALUATION
• Knowledge of Professionalism MCQ’s, short answers, OSCE’s• Professional Behaviors Behaviors used at all levels
derived from attributes
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The P-MEXForm &
BehaviorsValidated
Listened actively to patientShowed interest in patient as a personRecognized and met patient needsExtended his/herself to meet patient needsEnsured continuity of patient careAdvocated on behalf of a patient Demonstrated awareness of limitationsAdmitted errors/omissionsSolicited feedbackAccepted feedbackMaintained appropriate boundaries Maintained composure in a difficult situationMaintained appropriate appearanceWas on time Completed tasks in a reliable fashionAddressed own gaps in knowledge and skillsWas available to colleaguesDemonstrated respect for colleaguesAvoided derogatory languageMaintained patient confidentialityUsed health resources appropriately
Cruess et alAcademic Medicine, 2006
OBSERVABLE BEHAVIORS USED TO EVALUATE PROFESSIONALISM AT McGILL
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Student Evaluation of FacultyPhysicianship 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
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Faculty performance (global ratings)
4715 ratingsUnsatisfactory Fair Good Very Good Excellent
0
500
1000
1500
2000
2500
Freq
uenc
y
n = 43
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Resident performance (global ratings)
Unsatisfactory Fair Good Very Good Excellent0
200
400
600
800
1000
1200
1400
Freq
uenc
y
n = 23
2675 ratings
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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
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•
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
WHERE ARE WE NOW?
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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
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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
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THANK YOU!
Centre for Medical Education, McGill University