Ian Hart

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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

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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

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

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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

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PROFESSIONALISM

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

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The Challenge

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

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

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THE LITERATURE

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

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MUST DO BOTH !Teaching aloneremains
theoreticalExperiential learning alone
selective/disorganized knowledge of
professionalism and professional obligations

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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

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

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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

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Teaching Professionalism

• Undergraduate Postgraduate
• Year 1 Year 4
• ? Level of Sophistication
• social contract

Imparting the Cognitive Base Professionalism
gt gt gt gt gt gt gt gt
gt gt gt
? capacity to personalize professionalism
Promoting Self-Reflection
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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 medicines social contract.
• TELL A STORY

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Self-Reflection

• Definition purposeful thought provoked by
  learners
• 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
  

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The Physician Has Two Roles

• Healer
• Professional
• Served simultaneously
• Analyzed separately

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Healing and Professionalism
The concept of the healer
The concept of the professional
Middle ages Learned professions clergy,
law, medicine 1850Legislation 1900University
linkage The Present
Antiquity Hippocrates technology curing The
Present
Code of Ethics
Science
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Attributes
Competence Commitment Confidentiality Altruism Int
egrity / 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
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The Primary Role is that of the Healer
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Professionalism as the word is used generally
includes both roleswe use PHYSICIANSHIP
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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
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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 and
  to society.
• Derived from the Oxford English
  Dictionary (1985) and the literature on
  professionalism
• Cruess,
  Johnston, Cruess Teaching and
• Learning in Medicine,
  2004

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

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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

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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)

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The Social Contract

• Medicines 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

• Societys 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

Individual and Collective Responsibilities
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The McGill Experience1997 - 2006A Work in
ProgressThe result of the Efforts of Many
Individual Faculty Members
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GENERAL PRINCIPALS

• Integrated approach throughout undergraduate
• and postgraduate education.
• Activities throughout the curriculum
• Support of Deans office Chairs
• Multiple techniques of teaching.
• Formal Teaching
• small groups
• independent activities
• role models -faculty
• - residents
• Self-Reflection
• Evaluation linked to teaching
  Cruess Cruess
• Faculty Development Essential
  Medical Teacher,2006

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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/experienti
  al learning
• Participants became skilled group leaders/trained
  role models.
• Led to curricular change.
• ? Altered the environment.
• 
  Steinert, Cruess, Cruess and Snell
  Medical Education, 2005
• 
  

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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

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Content-Whole Class

• 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

lt
Prof 101 - 1st yr Prof 201 - 2nd yr Prof 301
3rd year
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Content- Individual Courses

• unit specific activities (small group)
• pre-clinical
• clinical
• humanism/narrative medicine
• spirituality
• community service

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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

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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

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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