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

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

Physicians must both

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

This is Important to Society

Neither economic incentives, nor
technology, nor administrative control
has proved an effective surrogate for the
commitment to integrity evoked in the
ideal of professionalism
Sullivan, 1995

PROFESSIONALISM

Traditionally taught by role models

It remains an essential method
It alone is no longer sufficient
Role models must understand
professionalism

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

 Effective teaching of professionalism must

reach both the head and the heart
This is the preferred learning style of the
present generation

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

MUST DO BOTH !
Teaching alone
remains theoretical

Experiential learning alone

selective/disorganized knowledge of
professionalism and professional
obligations

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

Before knowledge can be embedded

in authentic activities it MUST
first be acquired

HOW
Cognitive base
Self-reflection

Role modeling

The environment

teach it explicitly
encourage the active
process
requires knowledge and
self-awareness
must support
professional values

Teaching Professionalism
Undergraduate
Imparting the
Cognitive Base
Professionalism

Promoting SelfReflection

Year 1

>

Postgraduate

Year 4

Level>of Sophistication
>
> > >

>

>

social contract
capacity to
personalize
professionalism

>

>

>

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

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

The Physician Has Two Roles

Healer
Professional
Served simultaneously
Analyzed separately

Healing
Healing and
and Professionalism
Professionalism

The concept of the healer

The concept of the professional

Antiquity

Middle ages
Learned professions
clergy, law, medicine

Hippocrates

technology
curing
The Present

Code of
Ethics
Science

1850:Legislation
1900:University linkage
The Present

Physician
Healer

Caring/ compassion
Insight
Openness
Respect for the
healing function
Respect patient
dignity/
autonomy
Presence

Professional

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

The Primary Role is that

of the Healer

Professionalism as the word is

used generally includes both roles
we use
PHYSICIANSHIP

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

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

 The social contract in health care

hinges on professionalism.
It serves as the basis for the
expectations of medicine and
society.

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 calledGough:
a social
The contract
Social
Contract, 1957

The Social Contract

A mix of:

the explicit and the implicit

the written and the unwritten

- licensing laws, health care
ethics,
the Charter

legislation, codes of

legal and moral obligations

the universal and the local
Constantly evolving (being renegotiated)

The Social Contract

Medicines Expectations of Society

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

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

Individual and Collective Responsibilities

The McGill Experience

1997 - 2006
A Work in Progress
The result of the Efforts of Many
Individual Faculty Members

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

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 became skilled group leaders/trained role models.
Led to curricular change.
? Altered the environment.
Medical Education, 2005

Steinert, Cruess, Cruess and Snell

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

Content-Whole Class
Flagship activities- at regular intervals- required
lectures

small groups

<

Prof 101 - 1st yr

Prof 201 - 2nd yr
Prof 301 3rd year

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

Content- Individual Courses

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

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

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

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
Osler:
with your head
The Master Word in Medicine
In Aequanimitas