Report of Task Force

on

M.D.,C.M. Curriculum Renewal

March 19, 2004

Physicianship:

The Physician as Healer and Professional

[A]s you ought not to attempt to cure the eyes without the head, or the head without the body, so neither ought you to attempt to cure the body without the soul. And this…is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they disregard the whole, which ought to be studied also, for the part can never be well unless the whole is well. – Plato, Charmides

Executive Summary

A curriculum review process was undertaken in 2003. This was stimulated by faculty working groups on “professionalism”, on “healing and the medical mandate” and on the “evaluation of physcianship”. It culminated in the creation of a Task Force that was mandated to review the teaching of the “professional” and “healing” roles of the physician in the undergraduate medical curriculum. The Task Force had broad-based faculty representation. It met from October 2003 to March 2004.

The Task Force report includes a series of recommendations, the most significant being the reconfiguration of the units currently focusing on the therapeutic alliance, medical interview, physical examination and ethics & law into a series of five courses entitled: “The Physician as Healer & Professional”. It is further recommended that this be accompanied by the integration of physicianship issues into the remainder of the four-year program; be buttressed by the introduction of a longitudinal approach to evaluating professional behaviours; and be supported by initiatives aimed at nurturing self-reflective practice. Two innovative approaches to the latter include the creation of “physicianship” discussion groups and the use of portfolios; both appear as specific recommendations in the report. The Task Force underlines the importance of the clinical method, particularly communication skills, as the framework necessary for understanding, teaching, delivering and evaluating physicianship skills. If the Faculty endorses this report, more work will be needed in developing a detailed template for a clinical method curriculum. The report, accompanied by a manuscript “The Clinical Method”, prepared by Dr. Eric Cassell, in his role as a consultant to the Task Force, lays the foundation for this important next step. Many members of the Task Force have indicated a willingness to continue their involvement into the next phase of planning and development.

The report emphasizes that two specific requirements must be met in order to guarantee successful implementation: adequate resources for faculty development and for monitoring program effectiveness. The early introduction of Faculty Development programs will need to be a priority. The use of labor-intensive strategies such as one-on-one consultations and peer coaching may be necessary. Rigorous attention to curricular outcomes studies and on-going feedback and reassessment is considered essential if this initiative is to succeed in rallying the academic community.

The Task Force is confident that the public at large, University leadership, alumni, benefactors and potential donors will recognize that the reframing of the undergraduate medical curriculum can have a tremendous impact. A program that values the dual roles of the doctor as a professional and a healer, and that continues to emphasize a commitment to scientific rigor, will enhance the educational experience of the student, motivate teachers and will ultimately contribute to a better patient experience.

Table of Contents

A.Introduction and Historical Context1-2

B.Task-Force on M.D.,C.M. Curriculum Renewal

- mandate and composition3-4

C.Rationale for Change

C.1 – C. 35-6

  1. Vision and Scope of Change

D.1 – D.37-9

  1. Content and Methods of Teaching – Recommendations

E.1 – E.2311-20

  1. Student Assessment on Physicianship: General Recommendations

F.1 – F.621

G.Student Assessment on Physicianship: Specific Recommendations

G.1 – G.1222-24

H. Implications of Curricular Renewal on the

Office of Faculty Development24-26

I. Curriculum Monitoring and Program Evaluation26

J.Resources Required for Implementation

J.1 – J.727-31

K.Miscellaneous Issues 31-34

- timeline

- role of the McGill Centre for Medical Education

- role of the McGill University Skills Centre

- unresolved issues

L. Opportunities for Fund Raising35-37

M.References38-39

N.Signatures

O. Appendices# 1 -14

Abbreviations used in the report

AAMC = American Association of Medical Colleges

ACLS = Advanced Cardiac Life Saving (a course)

ALDO = Aspects Législatifs, Déontologiques et Organisationnels de la Pratique Médicale du Québec (Legislative, Ethical, and Organizational Aspects of Medical Practice in Québec)

AOA = Alpha Omega Alpha Honors Society

APPC = Academic Policy and Planning Committee (a committee of University Senate)

BCLS =Basic Cardiac Life Saving (a course)

BtB = Back to Basics (4thcurricular component)

BOM = Basis of Medicine (1stcurricular component)

CS = Communication Skills

CSPCO = Committee on Student Promotion and Curricular Outcomes

FACDEV = Faculty Development

GHHS =Gold Humanism Honors Society

ICM = Introduction to Clinical Medicine (2ndcurricular component)

LCME = Liaison Committee on Medical Education

MCQ = Multiple Choice Question

M.D.,C.M. = Doctorem Medicinae et Chirurgiae Magistrum (McGill’s medical degree - since 1862)

MEAP = Medical Education Assessment Project (Dartmouth College, New Hampshire)

MIHI = McGill International Health Initiative (formerly known as OMAF;

a volunteer student group)

MSOP = Medical Student Objectives Project (an initiative of the AAMC)

MSPE = Medical Student Performance Evaluation document (a.k.a Dean’s Letter)

OSCE = Objective Structured Clinical Examination

P-HP = Physician as Healer and Professional (proposed series of courses & events)

P-MEX =Physicianship Mini-Evaluation Exercises (an evaluation tool)

POM = Practice of Medicine (3rdcurricular component)

PP = Promotion Period

SAMA = Student Association for Medical Aid (a volunteer student group)

SAQ = Short Answer Question

SCTP = Subcommittee on Courses and Teaching Programs (a subcommittee of APPC)

SP = Standardized(or Simulated) Patient

A.Introduction and Historical Context

The organization of clinical,particularly hospital-based, education has not changed significantly since the time of Sir William Osler. Osler was instrumental in introducing usefuleducational methods, such as the emphasis on bedside teaching in the third year clerkships at JohnsHopkinsHospital in 1893. Although this clinical method, as practiced over the past century, has served the profession well, there are many indications that an update is necessary. Among the most important reasons for such a review are: 1) thechanging topography of health care delivery i.e. a shift from in-patient to ambulatory care settings; 2) a change in focus from acute illness to chronic diseasesdisability; 3) an astonishing proliferation of technology; and 4) numerous factors impacting on the nature of the patient-doctor relationship. With this background, the Association of American Medical Colleges (AAMC) has urged all North American medical schools to review their clinical education programs. This has served as one of the catalysts for the current review

The practice of medicine has been described as a science, an art and a profession. Medical schools by virtue of their selection process, curricula, institutional culture and the values they espouse are powerful forces in molding “doctors”. In great measure, theydetermine how their graduates will ultimately view the world, consider their role as a physician, and practice medicine. In support of the clinical methodcurrently inuse, most North American schools have, understandably, placed great emphasis on scientific methodology and the basic physical sciences (e.g. anatomy, biochemistry, physiology, etc). The art that is inherent to the discipline is taught in varying degrees and is often subsumed by the teaching of the “humanities”, biomedical ethics and the social sciences. In recent years, medical educators throughout North America, while thankfully not abrogating their responsibility to the traditional basic and clinical sciences as pillars of medical knowledge, have been placing increasing emphasis on the teaching of “professionalism”. This trend, present at McGill, has been an additional stimulus for curricular review.

The definition and nature of professionalism has been a source of some debate. A consensus has developed that it includes three fundamental elements: the organizational aspects of the profession (e.g. autonomous and self-regulating); the nature of the contract between society and doctors (e.g. primacy of patient welfare, social justice, based on trust) and a set of personal attributes (e.g. integrity, altruism). McGillUniversity, through the research of Dr. R. Cruess (formerly Dean of the Faculty of Medicine) and Dr. S. Cruess (formerly Director of Professional Services, RoyalVictoriaHospital), has been fortunate to be at the forefront of these developments. They have participated in the development of an International Charter of Professionalism and have been effective advocates for making appropriate modifications to our medical curricula. In collaboration with other faculty members, they created the McGill Working Group on Professionalism. This working group submitted a report, with a blueprint for curricular modifications, to the curriculum committee in April2003 (appendix 1).

Coinciding with the initiatives in “professionalism” anotherdevelopment occurred at McGill. It relates to the concept of healing. Dr. M. Kearney, a visiting professor during 2000-2002, and Dr. B. Mount, a palliative care expert, have emphasized the need for doctors to incorporate healing, as related to but distinct from curing, into the medical mandate. They have successfully introduced teaching modules on healing in the program. They have recruited over a dozen physicians, from a variety of specialties, to help promote the importance of this holistic approach to patient care. Under the auspices of the McGill Working Group on Healing & Health Care they submitted a report, in March 2003, promoting the integration of this concept throughout the program (appendix 2).

The two working groups, one on “Professionalism” and the other on “Healing”, in collaboration with the Faculty Development Office and the Centre for Medical Education, have helped define the core of what it means to be a doctor. We have reached a consensus that the doctor must serve two fundamental roles: that of the professional and the healer. We have borrowed the term “physicianship”, from the book entitled “Doctoring” by Dr. Eric Cassell,to refer to these combined roles. Both roles are served simultaneously, and while there is a great deal of overlap in the personal attributes required to fulfill these, they do, nevertheless, have a distinctive cognitive base and different historical backgrounds. Regardless of the focus, (curing, healing, caring, controlling, preventing, treating), it is self-evident that “physicianship” is enacted through the clinical method, in particular, communication skills. Any curricular renewal targeting physicianship must therefore include, as one of its elements, a reappraisal of how communication is taught and how the patient-doctor relationship is defined.

We recognize that any major modification to curriculum must be accompanied by a review of student assessment strategies. A preliminary analysis has already been completed by an ad hoc committee on the “evaluation of physicianship”, under the chairmanship of Dr. S. Prichard. It submitted a report in June 2003 (appendix 3). This report was subsequently forwarded, for independent appraisal, to Dr. Louise Arnold, Associate Dean for Medical Education, University of Missouri-Kansas City, School of Medicine. Dr. Arnold has provided very useful and pragmatic advice (appendix 4). Additional recommendations, by members of the McGill Working Group on Professionalism, were presented in January 2004 (appendix 5).

This curriculum review process has been catalyzed by a challenge put forth by the AAMC; been propelled forward by various working groups within the Faculty; and been inspired and given an important focus by the need for medical educators to renew and update the clinical method. The TaskForce has considered the appropriateness and feasibility of having Physicianshipserve as the leitmotif for a reframed curriculum and the clinical method as its modus operandi.

“The true method to teach medicine is the one appropriate to all natural sciences; … train their judgement rather than their memory and inspire them with that noble enthusiasm for the healing art that masters all difficulties”. Philippe Pinel

B.Task-Force on M.D.,C.M. Curriculum Renewal

Mandate:

  • to review working group reports (Professionalism; Healing; Evaluation of Physicianship) and consider their specific recommendations
  • to review the teaching of the humanities in the program
  • to review all current curricular courses & clerkships in order to determine if they are using opportunities optimally to teach and evaluate “physicianship”.
  • to recommend modifications to course content and teaching methodologies in the domain of “physicianship”
  • to recommend new module(s), if necessary, in order to meet the new objectives
  • to identify the facilitators and barriers to implementing specific recommendations.
  • to identify the resources (human, faculty development, financial, equipment, etc.) that will be required for implementation

Meeting dates:

October 21, 2003

November 5, 2003

November 14, 2003 (unit review session)

November 24, 2003 (unit review session)

December 3, 2003

January 19, 2004

February 19, 2004 (Communications Symposium)

March 10, 2004

The minutes of meetings are available upon request.

Task-Force Membership:

Name
Dr. Donald Boudreau(Chair) / Associate Dean, Medical Education

Dr. Yvonne Steinert (Ex-officio)

/

Associate Dean, Faculty Development;

Associate Director, Centre for Medical Education

Ms. Janet Butt(Secretary) / Student Records Officer
Dr. Manuel Borod / Internal Medicine
Dr. James Brawer / Basic Science
Mr. Matthew Cesari / Student Representative

Ms. Mylène Dandavino

/

Student Representative

Dr. Anna Derossis

/

Surgery

Dr. Carolyn Ells

/

Bioethics

Dr. Sharon Johnston

/

Resident Representative

Dr. Marc Laporta

/

Psychiatry

Dr. Stephen Liben

/

Pediatrics

Dr. Wendy MacDonald /

Pediatrics

Dr. Joyce Pickering

/

Internal Medicine

Dr. Maureen Rappaport

/

Family Medicine

Dr. John Setrakian

/

Internal Medicine

Dr. Charles Scriver

/

Pediatrics

Dr. Simon Young

/

Basic Science

Consultants

Dr. Louise Arnold

/ University of Missouri – Kansas City

Dr. Eric Cassell

/ WeillMedicalCollege of CornellUniversity

Dr. Richard Cruess

/ Centre for Medical Education, McGillUniv.

Dr. Sylvia Cruess

/ Centre for Medical Education, McGillUniv.

Dr. Michael Kearney

/ University of California, San Diego

Dr. Balfour Mount

/ Integrated Whole Person Care, McGillUniv.

“Graduates of McGill’s Faculty of Medicine have received an education that emphasizes the very highest standards in the care of the sick person by striving to meet the dual and complementary roles of the physician as professional and of healer”. S. Liben

C.Rationale for Change

C.1Pedagogic and institutional imperatives

  • The lack of integration of ethical, spiritual and economic issues into the curriculum was identified as one of nine weaknesses of the program by the LCME accreditation survey team visit in May 2000. (1)
  • Current LCME accreditation standards for the «Functions and Structure of a MedicalSchool» require that “behavioural subjects, medical ethics, human values, and cultural beliefs be included in the curriculum” (ED-10; ED-19; ED-21; ED-22; ED-23). (2)
  • The AAMC has recommended, in the MSOP, that each medical school develop learning objectives concerning the core professional attributes i.e. the physician as altruistic, knowledgeable, skillful and dutiful. (3)
  • Many innovations in medical education have focused on the traditional first phase of the curriculum while leaving the thirdand fourth years intact. This is also the case at McGill. McGill`s clinical rotations have not been subject to substantial change for many decades. The last curricular renewal process resulted in Curriculum ’94. It was and remains very successful and highly appreciated by students and faculty alike. The changes it introduced were primarily in the teaching of basic sciences; the clerkships were not modified. The link period, renamed Introduction to Clinical Medicine, was the object of minimal change. In response to this phenomenon, not unique to McGill, the AAMC has advocated for modifications to clinical education - the clerkships in particular. (4)
  • The need to place greater emphasis on professionalism has been accepted by many educational institutions including the Royal College of Physicians and Surgeons of Canada, as articulated in the CanMEDS roles. (5)
  • Student feedback suggests that the program has not been successful in conveying a holistic or integrated whole person approach to health care. As testament to this, less than 40% of graduates from the Class of 2002,when asked to predict the nature of their future clinical practices, anticipated having to “deal with many patients having behavioral and psychosocial issues”. (6)
  • Recent statistics regarding academic failures or dismissal from the M.D.,C,M. program confirm that breaches in professionalism are important factors in academic delays or failures.

C.2Professional and societal imperatives

  • Many professional organizations have advocated that the profession renew its commitment to professional values such as social responsibility and advocacy. (7)
  • The federal government has recommended that the profession, including medical schools, promote social responsiveness. (8)
  • The public has, in increasing numbers, gravitated away from conventional medicine towards alternative healers and complementary therapies. (9)
  • There is a widespread belief that medicine has abandoned some of its traditional roles in favor of an interventionist, highly technical, supra-specialized and fragmented approach to health care delivery. Some colleagues question the need for medicine to concern itself for the caring function arguing that this is in the domain of other health care professionals. Others challenge the premise that healing is part of the medical mandate. (10)
  • Patient complaints and litigation against doctors are often rooted in a perception that the treating physician lacked empathy, did not listen and/or did not treat the patient as a person. (11)
  • The issue of physician stress and “burn-out” (occasionally manifest as substance abuse and suicide) suggests that our graduates may not be well equipped to deal with the demands placed on individuals when in medical practice. (12)
  • There are increasing demands that graduates be able to learn and work in interdisciplinary environments. (13)

C.3Opportunities for change

  • The Dean, Deanery Council and Dean’s office staff all support curricular renewal.
  • The Faculty is fortunate to have local experts and champions on “Professionalism” and on “Healing in Medicine”. (14, 15)
  • The faculty is fortunate to have the enthusiastic support of external experts, in particular, Dr. E. Cassell and Dr. M. Kearney
  • The faculty will soon be equipped with an interdisciplinary surgical/clinical skills centre (hopefully by autumn, 2005). This will provide opportunities for enhanced communication skills training.
  • The provincial government is expected to allocate additional funds for clinical teachers.
  • There are opportunities for funding of initiatives aimed at increasing interdisciplinary teaching. Health Canada is expected to announce a call for proposals (in March 2004) to fund initiatives on “interdisciplinary education for collaborative, patient-centered practice” (IECPCP).

“The greatest difficulty in life is to make knowledge effective, to convert it into practical wisdom.” Sir William Osler