Home > Undergraduate Medical Program at McGill University
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
Context 1-2
B. Task-Force on M.D.,C.M. Curriculum Renewal
-
mandate and composition 3-4
C. Rationale for Change
C.1
– C. 3 5-6
D.1 – D.3 7-9
E.1 – E.23 11-20
F.1 – F.6 21
G. Student Assessment on Physicianship: Specific Recommendations
G.1
– G.12 22-24
H. Implications of Curricular Renewal on the
Office
of Faculty Development 24-26
I.
Curriculum Monitoring and Program Evaluation 26
J. Resources Required for Implementation
J.1 – J.7 27-31
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 Raising 35-37
M. References 38-39
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 (4th curricular component)
BOM = Basis of Medicine (1st curricular 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 (2nd curricular 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 (3rd curricular 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
useful educational methods, such as the emphasis on bedside teaching
in the third year clerkships at Johns Hopkins Hospital 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) the changing
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 diseases
& disability; 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, they determine how their graduates will ultimately
view the world, consider their role as a physician, and practice medicine.
In support of the clinical method currently in use, 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). McGill University, through the research
of Dr. R. Cruess (formerly Dean of the Faculty of Medicine) and Dr.
S. Cruess (formerly Director of Professional Services, Royal Victoria
Hospital), 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 April 2003 (appendix 1).
Coinciding with the initiatives
in “professionalism” another development 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 Task Force has considered the appropriateness
and feasibility of having Physicianship serve 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:
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 |
Weill Medical College of Cornell University |
Dr. Richard Cruess |
Centre for Medical Education, McGill Univ. |
Dr. Sylvia Cruess |
Centre for Medical Education, McGill Univ. |
Dr. Michael Kearney |
University of California, San Diego |
Dr. Balfour Mount |
Integrated Whole Person Care, McGill Univ. |
“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.1 Pedagogic and institutional imperatives
C.2 Professional and societal imperatives
C.3 Opportunities for change
“The greatest difficulty in life is to make knowledge effective, to convert it into practical wisdom.” Sir William Osler
D. Vision and Scope of Change
D.1 Current status
The M.D.,C,M, program is currently based on the following key characteristics and principles:
Admission and Recruitment
Model of Graduate
Educational Principles and Educational Methods
Program Content
Locus of Learning
Student and Program Evaluation
D.2 New vision
The program reaffirms its commitment to the guiding principles outlined above.
We nevertheless propose the
following modifications: (the changes are in italics)
Admission and Recruitment
Model of Graduate
Educational Principles and Educational Methods
Program Content
Locus of Learning
Student and Program Evaluation
We should take
care not to make intellect our god; it has, of course, powerful muscles,
but no personality.” Albert Einstein
D.3 Scope of change
The overall structure of the
curriculum, with the four components, BOM, ICM, POM and BtB, will be
preserved. The program will retain most of its current courses. Key
features such as the small group program in BOM; departmentally based
clerkships; an emphasis on patient contact; hands-on experience and
bedside teaching; and traditional methods of teaching (e.g. cadaver
dissection) will not change. There will be changes throughout the program
although they will be more substantial in certain areas (e.g. the ICM
component).
While the current curriculum
will be clearly recognizable in the “new”, modifications required
to implement the new vision will represent much more than mere “adjustments”
or “tinkering”. The new guiding principles will infuse and characterize
all courses and program activities. A longitudinal (umbrella) integrated
course on “The Physician as Healer and Professional” will be introduced.
It will incorporate much of the content related to the clinical method.
There will be a greater degree
of centralized oversight of clinical components, new strategies for
teaching and new opportunities for role-modeling.
It is important to note that
implementation of the changes will not be accomplished “overnight”.
While many important changes will be introduced at the start, other
aspects of the change will be progressive, over a number of years, as
experience is gained and as the expertise of the faculty is enhanced.
Also, the recommendations are not “etched in stone” and modifications
should be expected “along the way”.
Physicianship is a role – a set of performances, duties, obligations, entitlements, and limitations connected to a function or status.”
Eric Cassell
E. Content and Methods of
Teaching – Recommendations
In order to best appreciate
the following recommendations, the reader should consult the curriculum
schema. The current curriculum structure is presented in appendix 7
and the proposed changes are outlined in a modified schema in appendix
8.
Changes affecting all four
curricular components:
E.1. In recognition of the adoption of “physicianship” as the organizing theme of the program, a series of courses entitled “The Physician as Healer and Professional” (PHP) will be incorporated in the curriculum. These five courses will be fully integrated. The clinical method (including communication skills), professionalism, biomedical ethics and healing will be constant threads in the series. The proposed courses, with their primary focus, are:
| Course | Focus of course* |
| The Physician as Healer & Professional – A | Patient-Physician Relationship and Alliance Building; Professionalism; Ethics; Cultural Competence; Observational Skills |
| The Physician as Healer & Professional - B | Communication Skills; Medical Interview |
| The Physician as Healer & Professional - C | Physical Examination; Logic of Medicine |
| The Physician as Healer & Professional - D | Healing; Ethics; Clinical Epidemiology |
| The Physician as Healer & Professional - E | Communication; ALDO-Québec; Professionalism Reviewed |
* This is subject to change and will need in-depth review before implementation.
There will also be a series of events related to physicianship. These events will be identified as integral to the program of physicianship even though they do not result in university credits, are “elective” in nature (i.e. attendance is generally optional), and for the most part, are “one-day events”. These would include:
P-1: Orientation Day Sessions on Professionalism
P-2: Student Wellness Day
P-3: Commemorative Service for Donors of Bodies
P-4: Dr. Joseph Wener-Donning the Healers Habit (i.e. a White Coat) Ceremony
P-5: Student Extracurricular Projects Presentation Day
P-6: Meetings of Physicianship Discussion groups (with use of portfolio)
P-7: Annual Osler Lecture and Banquet
P-8: Submission of Physicianship Portfolio
P-9: Graduation & Convocation
ceremonies
“Neither economic
incentives, nor technology, nor administrative control has proved an
effective surrogate for the commitment to integrity evoked in the ideal
of professionalism.” W. M. Sullivan
E.2. In recognition of the importance of role-modeling, the professionalization that occurs in the formal and informal curriculum, and in order to teach and promote self-reflection, all students will be assigned to a “physicianship discussion group” at the time of entry into the program. These groups will continue to meet throughout the 4 year program. The students will meet, in groups of 8, with a faculty member, at least 3 times per year, to discuss their personal evolution from “laymanship” to “physicianship” (P-6). Attendance at these meetings will be considered mandatory. The meetings scheduled for third year may be facilitated by excusing the students from any clinical responsibilities on three specific half-days (i.e. recall days). Currently the students are “recalled” for the “Palliative Care day”; this would no longer be necessary in the proposed curriculum. Responsibilities of the discussion group leaders would include an annual review of a physicianship portfolio and the submission of a “portfolio status report” to the Dean’s office, in time for Dean’s letter submission (see recommendation #3). Students would have the option (but would not be obliged) to use entries in their portfolios as triggers for discussion. The leader might also assume a mentorship role vis-a-vis a particular student or student(s) in the group, although this would be optional.
Note: This recommendation does
not apply to the students registered in the Faculty of Dentistry.
E.3. In recognition
of the importance of self-reflection,
self-care and self-knowledge, all students will be required to maintain
a “physicianship portfolio”. The portfolio will be reviewed yearly
with the leader of the physicianship discussion group. It will be used
primarily for formative purposes. An example of a portfolio system,
tailored to the M.D.,C.M. program, is presented in appendix 9. Given
the lack of experience with this strategy at McGill’s Faculty of Medicine
and the extent of resources required to institute and maintain such
a tool, it is further recommended that the program remain highly flexible
with respect to its implementation. It was considered reasonable to
embark on a pilot project, with on-going mandatory review, by both faculty
and student body. Given the longitudinal nature of the proposal, the
goal from the very outset would be to implement this for one entire
cohort of students (i.e. a 4 year pilot). However, in the event that
significant and un-remediable problems were to arise, the program would
be quite willing to abandon this specific aspect of the curriculum.
Also, we recommend that it not be implemented unless the resources are
adequate to permit the review of portfolios by faculty members.
E.4. In
recognition of the importance of the professional and healer roles of
the physician, a longitudinal evaluation system focused on physicianship
will be developed. It will be formative and summative. The clinical
evaluation forms will be modified to include a section on physicianship
(appendix 10). A new section, entitled “Physicianship” will be added
to the Medical Student Performance Evaluation (MSPE) (appendix 9).
E.5. In recognition of “responsibility to society” as a professional attribute, the faculty will provide support, including logistical and financial, (akin to the student research bursary program), for community-based education projects. These projects, as with the case of summer/winter research projects, will be offered on a volunteer basis. They will be given formal faculty endorsement by including a notification on the MSPE. The annual “Student Research Day” will be renamed the “Presentation Day for Student Extracurricular Projects” (P-5). The community based projects will therefore be given a level of visibility similar to that of research projects. Students having done extra-curricular activities in the third world (e.g. with SAMA, MIHI) could also be invited to make a presentation. The Presentation day would be organized co-jointly by the Associate Dean for Research and the Academic Director of the community-based education projects. There would be no regular classes, small groups or laboratories scheduled on that day, permitting all second year students to attend.
Notes: These community-based
education projects do not replace or conflict with the projects that
the Dept. of Family Medicine currently requires of students in their
clerkship. Start-up funds for this type of program are available
through the Caring for Community program sponsored by the AAMC and the
Pfizer Medical Humanities Initiative (www.aamc.org/caringforcommunity) (appendix 11). An additional source
of funding may include the Dr. Alice Chan-Yip fund in multi-cultural
medicine; it is currently under development.
E.6. In recognition of the
fundamental role of the clinical method in defining and supporting the
professional and healer roles of the physician,
the program will renew its teaching of various elements of the clinical
method. The goal will be to develop and disseminate a unique McGill
approach to teaching the clinical method. It will use the manuscript,
“Teaching the Clinical Method”, prepared for the Faculty by Dr.
Eric Cassell, for guidance and inspiration (appendix 12). This is a
keystone of curriculum renewal. It will require priority attention.
E.7. In recognition of the fact that the professional and healing roles are enacted primarily through patient-physician interactions, and in order to comply with accreditation standard ED-19 mandating specific instruction in communication skills (CS), a longitudinal and integrated approach to teaching CS will be developed. The program will rely on a formal, previously validated model such as the Bayer-Fetzer approach or the Calgary-Cambridge Guide (18, 19) (appendix 13). The Bayer-Fetzer approach is particularly attractive because of its ease of use (23 items vs. 71). It is anticipated that modifications to it may be required in order to adapt it to our needs and institutional culture. The responsibility of teaching content in this domain will reside primarily, but not exclusively, in the “Physician as Healer and Professional” courses. We are aware of the potential for CS, learned in the early phases of medical school curricula, to deteriorate by fourth year. Given the powerful effect of clerkship experiences in reinforcing or corroding the effects of intensive CS training, we recommend that:
The introduction of a communication
skills curriculum will likely require an implementation committee; the
director and/or manager of the Skills Centre should be invited to sit
on this committee. In addition to the consideration of basic skills,
this committee should explore the need to teach advanced topics in communications
e.g. breaking bad news; communicating with an interpreter; multiculturalism;
effective communication when under pressure; etc. Furthermore, it is
anticipated that modifications will be required to the McGill case report
format and the case-construct template developed for the electronic
curriculum.
E.8. In recognition of the new emphasis to be placed on non-cognitive attributes of candidates to medical school; in order to comply with accreditation standard MS-1; and in response to the recent increase in academic failures and delays (a significant proportion related to issues of professionalism) this Task-Force recommends that:
Note: The committee was informed of reviews done on students who have experienced academic difficulty and that Dr. P. Beck, Associate Dean, Admissions, has already initiated a review of the admissions process. A consulting firm, having previous experience with medical school admissions (HayGroup), has prepared a preliminary report. This report has suggested optimizing the selection process by using a competency model for the interviews. The status of this proposal will be clarified this spring.
Note: The committee was also
informed that, due to impending changes in government decree on medical
student funded positions in the four Québec schools, there is likely
to be significant modifications to the “make-up” of the class (i.e.
a significant reduction in both the international and out-of-province
cohorts balanced by an increase in the Quebec cohorts; and an important
shift in the degree/Med-P ratio with an increased proportion of Med-P
candidates). It is noted that diversity of student body was identified
as a strength in the 2000 Accreditation survey and that these new provincial
decrees have the potential to diminish diversity.
Changes to the orientation
to the M.D.,C.M. program:
E.9. In recognition
of the adoption of physicianship as the organizing theme of the program;
given that it includes the professional role, and given the requirement
to meet knowledge objectives on the nature of professionalism,
orientation day will be redesigned (P-1). There will be a one-day orientation
to professionalism; it will discuss professional responsibilities. A
conceptual link will be made between professionalism and students will
be helped to understand the rationale underpinning the requirement that
they register with the Collège des médecins du Québec.
Changes to the BOM component:
E.10. In recognition
of the potential for the first component of the curriculum to underline
and role-model appropriate professional behaviours, of the importance
of early experiences in contributing to the
enculturation of medical students, and in order to comply with accreditation
standard IS-15, all BOM units will be required to incorporate a
minimum of one learning experience on some aspect, in addition to competence,
of physicianship and to include a few questions on their final exam
that test knowledge base of some aspects of professionalism. Although
this will be enforced by the Curriculum Committee, the nature of the
experience will be negotiated between the Unit Chair and the “Director”
and/or body responsible for implementation of the new curriculum (see
appendix 14).
E.11. In recognition of the adoption of physicianship as the organizing theme of the program, and in order to comply with accreditation standard ED-19, the longitudinal first year courses currently covering this content, ITP & ITPM, will be reorganized and refocused. It will be given a new name, the “Physician as Healer and Professional – A”.
The course may include the
introductory elements of teaching communications skills; the nature
of the patient-physician relationship, including alliance building;
observational skills; medical ethics; history of medicine; knowledge
objectives related to the professional & healer roles of the doctor
and a few basic features of the physical examination. Use will be made
of videotaped encounters with SPs.
“One must constantly
ask oneself, ‘Whom do I serve’? With this uppermost in one’s
mind, physcianship will be nurtured.” C. Scriver
Changes to the ICM component:
E.12. In order to comply with accreditation standards ED28, ED-29, to teach the clinical method effectively; to make efficient use of newer teaching venues, including the Skills Centre; and to permit the offering of a longitudinal experience in physicianship, ICM will need to be reorganized.
One possible model would be to create three courses:
Note: The Undergraduate Medical
Education Committee, Dept. of Medicine, has given its qualified support
for this proposed structure.
E.13. In order to facilitate integration of basic and clinical science and to deliver an appropriately sequenced approach to the clinical method, a limited number of key and/or representative aspects of physical examination (currently covered in the ICS module) will be repositioned earlier in the curriculum. For example, surface anatomy, use of the stethoscope and reflex hammer can be taught in the revised Unit 9A/B, at an appropriate time (stethoscope use coinciding with Unit 2 and reflex hammer use coinciding with Unit 6). While some observers are questioning the appropriateness of continuing to teach the traditional detailed physical examination (20) we are of the opinion that this is important because: doctors must continuously be exposed to the normal* and its variations in order to be better at identifying the abnormal; it represents a unique and appropriate opportunity for the doctor to connect tangibly with the patient; and it involves observation, a fundamental skill (to be covered in year 1). The ICS course will be retired; its content will be folded into “Physician as Healer and Professional – C”, offered at the beginning of ICM. It is vital for students to: consolidate skills learned earlier; integrate portions of the physical examination learned earlier into a coordinated “complete” physical; apply it to an actual patient; and record the findings in the prescribed format. It is anticipated that increasing use will be made of Standardized Patients.
* There is logic in repositioning
a few basic elements of the physical examination to the phase of the
curriculum where the focus is on “the normal”.
E.14. In order
to avoid unnecessary duplication and confusion, the course currently
referred to as “Professional Skills” (includes ICS, Medical Ethics
& Health Law, BCLS, Evidence-Based Medicine) will cease to exist.
The ICS will be “re-packaged” as per # 12. The BCLS will continue
to exist as a stand-alone module, offered in the early part of ICM.
Medical Ethics & Health Law will be integrated throughout the “Physician
as Healer and Professional” courses. The Evidence Based Medicine (EBM)
course will also be included in “The Physician as Healer & Professional
– C”. EBM was previously called “Critical Appraisal and
Informed Medical Practice”; it will revert to its original title.
E.15. In recognition
of the requirement to ensure that students have developed basic competencies
in the Clinical Method, to prepare our students maximally for the MCC-Part
2 and the USMLE Step 2 Clinical Skills exam,
and to comply fully with accreditation standard
ED-27, the program will introduce a skills-based, ICM exit examination.
It will include encounters with SPs. All disciplines having input into
ICM will be required to contribute to this exit examination. It will
not replace the end-of-unit ICM exams. The ICM exit exam will be a requirement
for promotion into clerkship.
Changes in the POM component:
E.16. In an effort to emphasize physicianship at a key transition point (i.e. start of clerkships), and given the opportunities provided by the rearrangements in ICM, and in order to better prepare our students for patient care responsibilities, a fourth course in the “Physician as Healer and Professional” series will be developed and introduced at the start of clerkships. It will focus on 1) the healing role of the doctor, by using a conceptual framework for “whole patient care” and 2) the use of technology (e.g. modern imaging techniques) in clinical decision making. The following issues may be considered: the doctor and the patient as individuals (persons); boundary issues; how to deal with the situation of a patient who has just died; creating a healing space; self-care (“Physician heal thyself”); the nature of therapy; a few selected topics in ethics and medical education (e.g. being left alone, confidentiality, medical error); palliative care issues; team-work & the nature of other health care professionals. Students will be introduced to parallel charting. It is expected that the Dept. of Psychiatry and Dept. of Epidemiology and Biostatistics will make important contributions. There may be opportunities for interdisciplinary teaching.
(Note: students will also take
the ACLS module during this course).
E.17.
In order to facilitate peer (student-student) teaching and collaboration,
and in response to the advice of clerkship directors,
the assignment of students to their clerkships sequences will be done
by random selection.
“Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?” T.S. Elliot
E.18. In order
to integrate physicianship issues throughout all units in the curriculum,
a matrix (i.e. educational blueprint) will be developed for the entire
program. Consultations with unit chairs, sponsoring departments and
the curriculum committee will be necessary (see Appendix 14 for a draft,
incomplete, template)
Changes in Back the Basics
component:
E.19. In deference to the unifying theme of “physicianship”, the Communication Plus course will be renamed: The “Physician as Healer and Professional– E”. It will continue to focus on advanced issues in communication and medical ethics. It will also provide an opportunity, prior to graduation, to review key concepts in professionalism including: the social contract and the student’s future role; the general organization of health care, medicine and hospitals; and conflicts of interest that can arise in practice, research and personal life. Students would be invited to consider their future roles as professionals and healers in the context of the discipline to which they will have just been matched.
Other changes to curriculum
structure and management:
E.20. In view
of the long-standing Faculty tradition of delegating responsibility
for longitudinal assessment of students’ academic performance (including
personal & professional conduct) to the student promotion committee;
in view of a long track record of rigor, yet fairness; in view of
an accreditation standard (MS-36) that
permits students to review and challenge their records; and
in view of institutional requirements that guarantee student
evaluations “free of bias”,
the administrative ramifications of the new physicianship evaluation
system will need to be considered in detail. For example, the tradition
of avoiding “forward feeding” will be a particularly important issue
for those faculty members participating in the longitudinal, four-year,
physicianship discussion groups.
E.21. As a consequence
of changes to ICM and POM, the definitions and timing of the Promotion
Periods (PP) will need to be modified as follows:
| Current | Proposed | |||
| Units included | Start & end dates | Units included | Start & end dates | |
| PP I | BOM 1-6; ITP | Aug - June | BOM 1-6; PHP-A | Aug - June |
| PP II | BOM 7,8; ITPM | Sept- Dec | BOM 7,8; PHP-B | Sept - Dec |
| PP III | ICM* | Jan - Sept | ICM (includes PHP-C) | Jan - June |
| PP IV | POM | Sept- Dec | POM (includes PHP-D) | Aug - Dec |
| PP V | BtB | Jan - May | BtB (includes PHP-E) | Jan - May |
* Note: ICM currently finishes
in Sept of 3rd year; in the new curriculum, it would finish
in June of 2nd year. The current ICM elective is therefore
moved to the POM component.
E. 22. In recognition of
the importance of physicianship throughout the program, the Molson
Software Development team will be asked to include “physicianship”
as they develop the electronic (web-based) clinical case construct.
Parallel recommendation
(not related to the physicianship program):
Although the following recommendation
is not directly linked to physicianship, if it were to be adopted, it
would be appropriate and less disruptive to introduce at the same time
as the other curricular modifications.
E.23. Given the provincial government’s stated goals of ensuring access to health care
in rural settings; the introduction of incentives (e.g. funds to pay for housing and travel);
the introduction of penalties (e.g. linking the number of allowable residency slots to
the status of rural medicine in the undergraduate program); and given mounting
evidence that training in rural sites promotes recruitment and retention at these sites,
consideration should be given to introducing a mandatory rural rotation in Family
Medicine. This should be a minimum of 3 weeks in duration. It is preferable that the
the students be in their final year of training. The clerkship year is already “full” and
to modify it would prove extremely difficult. The number of elective rotations is already
at a minimum; a one month elective was cancelled several years ago in order to permit
the introduction of a clerkship in Geriatric Medicine. The Back to Basics component
may provide opportunities. Consideration should be given to modifying its structure in
order to accommodate a rural rotation. Possible solutions might include: decreasing the
amount of time devoted to molecular biology (from 2 to 1 week); decreasing the amount
of time devoted to the seminar option in the humanities (from 4 to 3 weeks); reorganizing
Medicine & Society; retiring the “Ambulatory Medicine” course.
Note: the Department of Family Medicine has been consulted on this issue. Their
preliminary response is supportive. There would, however, be important hurdles. It is
unlikely that we could recruit sufficient numbers of rural sites to accommodate up to 160
students at any one time! Back to Basics would have to be reorganized in order to permit
several different sequences (preferably four) so that only 1/4 of the class (i.e. 40 students)
at a time would require
placement during the period January to April of fourth year.
"It is much more important to know what kind of patient has a disease
than to know what kind of disease a patient has".
Caleb Parry, Physician to Coleridge.
Summary:
| specific recommendations - curriculum content on physicianship: | |
| develop a series of five courses on the “Physician as Healer & Professional” (PHP) | E.1 |
| introduce “Physicianship Discussion Groups” for students, in all four years | E.2 |
| introduce “Physicianship Portfolios” | E.3 |
| develop a longitudinal assessment of student competence in “physicianship” | E.4 |
| develop Community based education projects (akin to research bursary program) | E.5 |
| renew teaching of the “Clinical Method” & develop a unique McGill approach | E.6 |
| adopt a formal and explicit approach to the teaching of communication skills | E.7 |
| review candidate recruitment and admissions in light of curricular modifications | E.8 |
| modify program orientation content | E.9 |
| mandate introduction of “physicianship” content in each of BOM units | E.10 |
| retire ITP/ITPM courses; reformat as PHP-A and PHP-B | E.11 |
| restructure ICM component | E.12 |
| teach aspects of physical examination earlier; retire ICS and reformat as PHP-C | E.13 |
| restructure Professional Skills unit; retire Medical Ethics & Health Law | E.14 |
| introduce a skills-based ICM exit examination; it should include an OSCE | E.15 |
| develop a new course called PHP-D (a reframed “Introduction to POM) | E.16 |
| assign students to clerkship sequences on a random basis | E.17 |
| develop an educational blueprint for program | E.18 |
| retire “Communications Plus”; rename it PHP-E | E.19 |
| review new promotion regulations and obtain legal input | E.20 |
| modify definitions and timing of Promotion Periods | E.21 |
| modify the clinical case construct used by the electronic curriculum | E.22 |
| a parallel recommendation: | |
| introduce a mandatory rural rotation in Family Medicine | E.23 |
“The most important
problem for the future of professionalism is neither economic nor structural
but cultural and ideological. The most important problem is its soul”
E. Freidson
F.
Student Assessment on Physicianship: General Recommendations
F.1 Focus:
It will rest on the underlying principle that “physicianship” is a matter of an “academic” - as opposed to “non-academic” nature.
It will focus on behaviours - but not to the exclusion of knowledge (e.g. cognitive basis of professionalism), skills (e.g. communication) or attitudes.
It will aim to identify
acceptable and unacceptable performance levels – but not to the
exclusion of documenting exemplary behaviours or performances.
F.2 Purposes:
It will have formative
(i.e. feedback for primary prevention and continuous self-improvement)
and summative purposes.
F.3 Format:
It will be unit-specific (i.e. an integral part of each course or clerkship) as well as
longitudinal & cumulative.
The longitudinal evaluation will not be a course. All courses, units
and clerkships will contribute to the cumulative evaluation. The longitudinal
evaluation will be reviewed at the end of each promotion period; it
will be a promotion criterion.
F.4 Potential Consequences for Student Arising from the Longitudinal Evaluation:
F.5 Underlying Evaluation Principles and Strategies:
F.6 Institutional Jurisdiction:
The Committee on Student
Promotion and Curricular Outcomes (CSPCO) will continue to exercise
final authority, subject only to appeal, on all aspects of student
academic progress, including “physicianship”.
G. Student Assessment on
Physicianship: Specific Recommendations
G.1 The Director of the
Physicianship program will maintain a longitudinal evaluation file on
physicianship for each student in the program. (It is anticipated that
the dossier will be kept in an electronic format). At a minimum, each
file will be updated upon completion of each Promotion Period. An interim
copy of the physicianship longitudinal evaluation will be submitted
by the director to the Associate Dean, Medical Education & Student
Affairs, at the end of each Promotion Period (and on an ad hoc basis
should the need arise). Students will have access to this file as is
currently the case with other elements of their academic dossier.
G.2 The Faculty will create a list of “critical events”.
Critical events must be
reported as soon as possible to the appropriate University or Faculty
officers since they require immediate attention.
Such events involve unethical, unprofessional, negligent (i.e. medical
malpractice) and/or criminal conduct; they have the potential to cause
major harm or damage to patients, colleagues, teachers, program, school,
faculty, university or profession. Without in any way limiting the
generality of the above definition, examples of reported incidents that
constitute a “critical event” are provided in the list below. This
list is modeled on one developed by the University of Toronto. It should
be noted that it is not all-inclusive and that the items are not listed
in any order of severity or importance:
| A report on an incident involving: |
| a violation of the criminal code |
| unprofessional conduct involving a patient (e.g. physical or verbal abuse) |
| sexual impropriety with a patient |
| an egregious violation of collegiality among members of health care team |
| falsification of a medical record, the altering of a prescription, or the issuing of a false certificate |
| misrepresentation of one’s qualifications |
| participation in a conflict of interest situation |
| the dating of a patient |
| the failure to be available while on call |
| a breach of confidentiality |
| the participation in patient care while being under the influence of alcohol or drugs |
| theft, damage, destruction of hospital property |
| plagiarism (as per article 15, Handbook of Student Rights & Responsibilities) |
| cheating (as per article 16, Handbook….) |
| theft, damage, destruction of university property (as per article 6, Handbook….) |
Ref.
(21)
G.3a) Students who do not
complete the registration requirements of the Collège des médecins
du Québec by the stated deadline are notified in writing by the Collège
with a copy to the Dean. A copy of this letter will be forwarded to
the Director of the Physicianship Program and will be included in the
longitudinal evaluation.
G.3b) Students who do not
complete the immunization requirements on time are “flagged” by
Student Health Services and the UGME office is notified. An officer
of the Dean’s office then contacts the student in writing. A copy
of this letter will be forwarded to the Director of the Physicianship
Program and will be included in the longitudinal evaluation.
G.4 BOM and Back to Basics
units will be asked to monitor unprofessional behaviours. The small
group evaluation form currently in use by BOM units will be modified
in order to include physicianship items. At a minimum, a column will
be added to permit the documentation of late arrivals to small group
session and space will be provided for narrative comments. The Department
of Anatomy & Cell Biology will also be contacted and their input
will be solicited with respect to creating or modifying the evaluation
form so as to take into account the context of the laboratory settings
(e.g. anatomy dissection lab)
G.5 All BOM units will be
required to evaluate some aspect of physicianship, to record this separately
and to submit this grade (or narrative comments) to the Director of
the Physicianship Program. These will contribute to the final
evaluation of the unit as well as to the longitudinal assessment.
A unit may choose to focus on the knowledge base and use standard test
strategies such as MCQ’s or SAQ’s.
G.6 The program will standardize
the student evaluation forms used in ICM units.
G.7 The form used to evaluate
and document physicianship behaviours will be fully integrated in the
forms used in ICM and POM (i.e. there will be one form only).
G.8 The ICM exit exam (as
per recommendation E.15) will include items on physicianship. Strategies
to accomplish this include: incorporating communication skills tasks
on OSCE stations; using post-encounter probes that assess understanding
of professional responsibilities; having one or more OSCE stations on
morality/ethics topics, etc.
G.9 Any objective examination
used in a clinical rotation (e.g. written examination or OSCE) will
include the evaluation of selected aspects of physicianship (knowledge,
skills and/or behaviours).
G.10 Students must attain
the expected standard on physicianship behaviours in order to be granted
a passing grade on a clinical rotation.
G.11 The Dean’s letter
(MSPE document) will be updated once each student has completed the
four year program. Any student who has experienced academic difficulties,
in any domain including physicianship, during the interval between release
of the Dean’s letter (i.e. Oct. of year 4) and graduation, will be
notified that an updated Dean’s letter will be forwarded to the residency
program to which they have matched.
G.12 As prerequisites to
the implementation of the new evaluation forms regarding physicianship,
the Faculty should solicit the input of the education coordinators who
will eventually be responsible for completing these forms. Consultation
of external experts and the incorporation of a research aspect (e.g.
psychometric testing) should also be considered.
“It goes
without saying that no man can teach successfully who is not at the
same time a student”
Sir William Osler
H.
Implications of Curricular Renewal on the Office of Faculty Development
Faculty Development is critical
to the design and implementation of a renewed curriculum. The proposed
revisions to the curriculum, even if they enjoy broad-based support
and endorsement by the academic community, will require a significant
and sustained faculty development program. It is anticipated that the
implementation of the key recommendations outlined in this report will,
in the first 2 years, be heavily focused on preparing and motivating
the faculty. Furthermore, many aspects of the recommendations will need
further refinement. For example, guidelines and specific content of
the physicianship portfolio has not yet been finalized. The communication
skills approaches will need to be developed to an operational level
and disseminated; this is considered a priority. The possible contributions
of the Skills Center to the teaching of the clinical method will need
a detailed analysis. It is anticipated that, as these are addressed,
the office of Faculty Development will be a key partner with the Director
of the Physicianship program.
Faculty development in the area of “physicianship” faces a number of unique challenges:
Moreover, we will need to address
these challenges at different levels. At an individual level we will
need to build motivation for learning; overcome resistance; and make
the implicit, explicit. At a program level we will need programs
that focus on content and teaching methods. Innovative FACDEV
methods and strategies will need to be developed. At a systems level
we will need to promote “buy in”; address the organizational climate
and culture; identify opportunities for teaching and learning; determine
the need for specialty-specific training; train the trainers and facilitate
dissemination.
With regard to specific faculty development methods, the following should be considered:
A “distributed model” of
Faculty Development is likely to be the most effective strategy for
sustaining this revised curriculum.
The following curricular changes will require Faculty Development input, support and involvement:
- teaching of physicianship – content and methods. This includes role modeling, preparing the leaders of the physicianship discussion groups, teaching with portfolios, teaching language & narrative competence, teaching an explicit approach to communication skills, integration of physicianship in clinical teaching, etc.
- evaluating physicianship and its components
- preparing a core group of faculty developers in this domain in order to implement a distributed model
providing educational consultations to individuals/committees responsible for the “Physician as Healer & Professional” courses; assisting the clerkships with deployment of their objectives in physicianship teaching and evaluation; interfacing with the McGill University Skills Centre; promoting the use of on-line learning; etc.
collaborating in initiatives aimed at promoting and supporting the educational mission e.g. faculty orientation and mentoring, support for research in medical education, etc.
I.
Curriculum Monitoring and Program Evaluation
The Task Force considers program
evaluation to be of utmost importance. It recommends strongly
that the Faculty provide sufficient financial support to track program
effectiveness.
Strategies for monitoring outcomes can include the following:
Ref:
Proposal by Ingram & Company, March 12, 2004
A measure of success
of the new curriculum: if its graduates never once, during their professional
lives, state to a patient, “There is nothing more I can do for you”.
D. Boudreau
J. Resources Required for Implementation
The Director is appointed by
the Dean, in consultation with the Associate Dean, Medical Education.
The term of appointment would be the “standard” 3 years, renewable.
This individual would report to the Associate Dean, Medical Education.
The Dean’s office staff would need reorganization in order to better
reflect changes to the curriculum. A high level managerial staff (e.g.
M-2) would be required along with significant clerical support. As an
example, the current education coordinator for ITP/ITPM/Medicine &
Society, might theoretically assume managerial responsibilities for
all aspects of the “physicianship program”. She would need a minimum
of one clerical support staff.
Responsibilities: The director would oversee the entire physicianship program. Specific duties would include:
Costs:
| Total
cost:
approx. $75,000 per annum |
J-2
McGill University, Faculty of Medicine, Physicianship
Interest Group:
Definition:
a group of faculty members, (full-time or part-time clinicians), who
participate in the physicianship program of the undergraduate medical
curriculum
Recruitment: It is expected that a pool of approx. 80-100 members will be needed.
The members would be appointed by a Dean’s committee.
The appointment would
ordinarily be for 4 years, renewable. There is also the expectation
that the member will participate in orientation sessions and mandatory
faculty development activities during the year prior to commencement.
Responsibilities of members:
There would be three levels of participation: A, B, C:
| Tasks | A | B | C |
| attendance at an orientation session, at the annual “de-briefing” session, and at selected Faculty Development workshops | X | X | X |
| lead a physicianship discussion group (3 meetings per yr) | X | X | X |
| review student’s
physicianship portfolio annually and
submit the portfolio status report in student’s 3rd year |
X | X | X |
| attend the
Student Project Presentation Day and/or
White Coat Ceremony |
X | X | X |
| participate in at least two small group sessions (per year) of the physicianship courses | X | X | X |
| act as group leaders in the ITP & ITPM small group program | X | X | |
| participate as an “ICS” instructor | X |
Benefits for interest group members:
| Total
cost (for level A participation)
approx. $40,000 (yr 1); $80,000 (yr 2); $120,000 (yr. 3); $160,000 (yr.4) Note: there will be increased costs related to ITP/ITPM small groups and ICS instructors as the amounts listed above for levels B and C represent new expenditures of approx. $24,000 per annum. Note: there would likely be additional costs related to supporting discussion groups i.e. a modest “discretionary fund” to help defray incidental costs |
J.3 Academic
Coordinator of Student Community Projects:
This individual, a faculty
member, would oversee the (elective/extra-curricular) student community
projects.
Responsibilities:
Costs:
| Total
cost:
approx. $17,000 (including student bursaries) |
| Total
cost of physical resources:
Office equipment itself will likely cost a minimum of $50,000. This excludes physical plant alterations and the cost of maintaining the Skills Centre. |
J.5 Curriculum Monitoring:
The MEAP project incurs minimal
expenditures (approx. $2,000 per year).
Ingram & Company, a firm with international expertise in identifying the experience that a complex, service oriented organization delivers to its “customers”, has presented a proposal that will identify appropriate benchmarks and curriculum “metrics”. The proposal has three phases:
Note: phase 1 has already
been funded by a grant from the Max Bell foundation. The funding of
phase 2 would require an additional $150,000. Phase 3 would cost approximately
$100,000 per year, ideally for 4 years.
The costs related to on-going
program evaluation will be substantial. It is anticipated that a significant
degree of support can be obtained through research grants. Nevertheless,
in the ideal setting, the program director should have access to a psychometrician;
this would likely cost an additional $30,000-$40,000 per year.
J.6 Faculty Development:
Given the scope of the change
that is envisaged, as well as the need for innovative faculty development
strategies, it is considered unlikely that the current FacDev office
would be able to meet the needs without significant additional resources
and/or major disruption in the programs it currently offers. It is clear
that physicianship will require a faculty development “champion”
as well as a dedicated team of faculty developers. The costs associated
with this will be substantial, particularly during the first two years.
A preliminary analysis of the additional resources that will be required
is summarized in the following table:
| Item | Estimated cost |
| a “core group” of physicianship Facdev trainers | $10,000 per year X 6 = $60,000 |
| stipends for “peer coaches” | $30,000 per year |
| clerical support for this initiative | $30,000 per year |
| additional financial support for the Associate Dean and “a physicianship core group” director | $20,000 per year |
| costs attributable to specific Facdev workshops, courses, seminars, consultations, etc. | $20,000 per year |
| Total
cost:
approx. $160,000 per year (for a minimum of two years) and $100,000 per year thereafter |
J.7 Total Cost:
It is estimated that the cost
of developing and delivering this program would be in the range of $550,000
for year 1 (October 2004 – October 2005) and approximately $450,000
per year thereafter. This estimate does not
include the costs related to developing, maintaining and staffing the
Skills Centre.
From an address made at the
1885 opening of the new Medical Faculty, McGill College:
“As no two faces,
so no two cases are alike in all respects, and unfortunately it is not
only the disease itself which is so varied, but the subjects themselves
have peculiarities that modify its action.” Sir William Osler
K. Miscellaneous
Issues
K.1 A possible timeframe
for “next steps”:
| Steps | Dates |
| Task Force report is delivered to Dean, Deanery Council and M.D.,C.M. Curriculum Committee. | March 2004 |
| Feedback to Task Force report is solicited. | April – July, 2004 |
| Phase 1 of Ingram & Company project (i.e. understanding the students’ and teachers’ perspective on curriculum, educational experience and physicianship) is carried out. | April – Aug., 2004 |
| Associate Dean attempts to secure additional financial support in order to fund Phase 2 of Ingram & Company project. McGill affiliated hospitals will be approached for financial. It is hoped that would be interested in having an enhanced understanding of the “patient perspective”. | May 2004 |
| Dean and Associate Dean meet with potential donors. | as soon as possible |
| Planning for Faculty Retreat. Faculty leadership will be asked to adopt the blueprint for Curricular Renewal. Invitees will include: Deanery Council; Department Chairs; Division Head – Geriatrics; Course/Clerkship Directors; Curriculum Committee; Faculty Development Steering Committee; CSPCO; Development and Alumni Relations Office; UGME staff; core members of Center for Medical Education; Task Force members. | July - Aug., 2004 |
| Faculty Retreat. | Sept. 2004 |
| Dean appoints
a Director of “M.D.,C.M. Physicianship Program”.
Office space for the Director and support staff has already been identified and is expected to be available by November 1st. |
Sept. 2004 |
| Official “launch date” for curriculum renewal project: October 2004 |
|
| Associate Dean presents M.D.,C.M. program revisions to appropriate University committees i.e. SCTP and APPC | Oct. 2004 |
| Dean informs LCME and CACMS of impending program modifications | Oct. 2004 |
| First
year priorities for the Director:
The Director would be working very closely with the office of Faculty Development to plan PHP course content, finalize communications skills program, finalize structure of portfolios and discussion groups, plan FacDev activities, finalize modifications to Clinical Method teaching, etc. S/he would also, in consultation with the Associate Dean, set up the Physicianship Coordinating Committee and appoint PHP course committees. There would also be the need to start recruitment of members for Physicianship Interest Group. Additional tasks would include administering the MEAP study for the Class of 2008 (as a baseline); assisting Ingram & Company; and participate in the ad hoc committee on interdisciplinary teaching. It is anticipated that ad hoc implementation workgroups would be necessary for:
It is hoped that many members of the Task Force will agree to continue working on selected work groups. |
Oct. 2004 – July 05 |
| First
year priorities of the Faculty Development Office:
These would include the recruitment of “trainers”, design and deliver first series of FACDEV activities (e.g. on portfolios; on leading discussion groups, etc.), assist in finalizing the communications skills program, work closely with the Director to set up the ad hoc implementation workgroups. |
Oct. 2004 – July 05 |
| Phase 2 of Ingram and Company proposal (understanding the patient perspective) is carried out; report is delivered to Faculty in August, 2005. | Jan. 2005 – July 2005 |
| Launch of courses begins (with the Class of 2009) |
|
| Roll-out
of first physicianship course i.e. PHP-A
Roll-out of Physicianship Discussion Groups and Physicianship Portfolio |
Aug. 2005 |
| Opening of Skills Centre | Fall of 2005 |
| Roll-out
of PHP-B
Roll-out of Community Based Projects |
Aug. 2006 |
| Roll-out
of PHP-C
Roll-out of new ICM component Roll-out of ICM exit exam |
Jan. 2007 |
| Self-study task-force is appointed by Dean, in preparation for LCME “Accreditation-2008” | Jan. 2007 |
| Roll-out of PHP-D | Aug. 2007 |
| Implementation of mandatory rural rotation in Family Medicine in the Back to Basics component | Jan. 2008 – May 2008 |
| LCME accreditation survey visit | Spring 2008 |
| Roll-out of PHP-E | Jan. 2009 |
| First class
to have completed the revised curriculum graduates.
Formal review by Faculty |
June 2009 |
Tempus fugit. Carpe Diem.
Note: the timeframe presented
above is extremely “tight”. It provides little more than a 6 month
period (October 2004 to August 2005) in order to finalize course content,
design FACDEV activities, recruit tutors, etc. Therefore, the expectations,
as outlined above, may not be feasible. In such an eventuality,
implementation may have to be more gradual; for example, the start-up
of discussion groups or portfolios may have to be delayed. Also, the
implementation of a comprehensive communication skills program and the
ICM exit exam requires that the Skills Centre be fully operational.
Any delay in that project would automatically result in staggered implementation.
Finally, full implementation assumes that resources will be forthcoming.
Inadequate financial support would, by necessity, result in a reappraisal
of the project.
K.2 Role of
the Centre for Medical Education:
The Centre for Medical Education will be an invaluable resource as this new curriculum is implemented. The Centre has assembled a group of individuals with expertise in the basics of pedagogy. It has been effective at analyzing educational issues using “group-think” and “brain-storming” strategies. It is ideally positioned to provide a consultative service to the team(s) that will be mandated to implement aspects of the revised curriculum. One domain in which interaction is likely to be particularly fertile is assessment of impact of the new curriculum. The Centre will almost certainly be consulted in designing, and hopefully collaborating in, studies of outcomes and program effectiveness.
The Director will receive a
copy of this report and will be invited to the retreat where future
directions will be discussed by the Faculty’s leadership.
K.3 Role of the
McGill University Skills Centre:
This facility, which we hope to see opened by the winter of 2005, is expected to be interdisciplinary. It is anticipated that the centre will require start-up costs of approximately $180,000 per year for salary support of centre manager, clinical instructors, SP recruiters and trainers, receptionist, administrative assistant & IT support.
It is impossible, at this point
in time, to give a precise estimate of the numbers of hours during which
the M.D., C.M. program would use the Centre. Consequently it is difficult
to give an accurate estimate of the proportion of the Center costs which
would end up being devoted to medical student education. In preliminary
planning meetings, it was predicted that this facility would be used
primarily for teaching communication skills, portions of the physical
exam, and to administer OSCEs (e.g. ICM exit exam, Surgery and Psychiatry
Clerkships).
K.4 Issues that remain unresolved
or incomplete:
(Dr. R. Cruess, Dr. S. Cruess, Dr. Y. Steinert, Dr. S. Ginsberg,
Dr. J. Herold McIlroy)
L. Opportunities
for Fund Raising
This project for curricular
renewal is potentially of a major scope and full implementation will
be costly. While it will clearly result in significant changes to the
educational experience of medical students, it is anticipated that it
will have impact beyond the confines of the M.D.,C.M. program. Since
the emphasis will be to update the clinical method, a core of all undergraduate
programs, there is a hope that innovations introduced at McGill will
serve as models for other medical schools. There is also the hope that
the “product” of the renewed curriculum, i.e. the future generation
of physicians and surgeons, will have a greater propensity to consider
their profession as one that is rooted in values and morality and endowed
with a covenant as opposed to simply a “job” or a “contract”.
There is the hope that these future graduates will be more vigorous
in defending long-held ideals of the medical profession e.g. altruism,
duty and social justice. Without in any way wanting to diminish the
critical sense of physicians, there is also every expectation that a
greater emphasis on self-reflective practice will result in practitioners
who derive a greater degree of satisfaction from their careers and who
are more tolerant of frustration.
Without wishing to overstate
the case, we are hopeful that this project, by having McGill differentiate
itself from other schools, can motivate the faculty, stimulate alumni
and benefactors of the university, galvanize students and teachers,
and contribute to a renewed sense of pride in the institution and her
mission.
We are confident that the public
at large will approve of the goals espoused by the “physicianship”
model, notably the emphasis on healing and on the patient-doctor relationship.
The reframing of the curriculum, as described in this report, has potential
to lead to profound changes in the manner in which health care is delivered
and we anticipate that donors will recognize this and wish to be involved.
The opportunities for donors will be varied. Support could take
many forms; the tables below, (one focused on the skills centre and
the other on the physicianship program), will identify some of these:
McGill University Skills
Centre:
| Required support | Naming potential | Minimum support |
| Equip examination rooms in the Skills Centre. | Honor the donor by naming the room. | $20,000 gift
per each examination room; Note: there will be 14 of these.
$100,000 per each. simulation room; Note; there are 3 of these. |
| Purchase simulators for the Skills Centre. | Yes | $50,000 to $500,000 gifts |
| Equip the Simulated Apartment | Yes | $50,000 gift |
| Equip the lounge area for SP’s | Yes | $10,000 gift |
| Support a specific element of the communication skills curriculum (e.g. “breaking bad news”, communicating with an interpreter: etc.). | Yes, a group or “guild” of actors could be created in support of specific objectives. | $20,000 gift |
| OR | ||
| Endow the Skills Centre facility* | Name the facility after the donor | Endowment of $5 million |
* The Faculty has already received
a grant from the provincial government, for up to $6 million, for infrastructure.
An additional $5 million is required for equipment and start-up costs.
The levels of support indicated in the above table are preliminary estimates;
they have not been reviewed with the Dean, the Skills Centre Steering
Committee or the Alumni and Development Office. They are presented primarily
for the sake of discussion and to establish the main “bottom-lines”.
They will need to be reviewed and approved by the Dean before any presentations
to external agencies or benefactors.
Physicianship program and
curriculum:
| Required support | Naming potential | Minimum support |
| Endow a chair in “The Clinical Method” or “Clinical Education” or “Physicianship”. | Named Chair | Endowment of $2 million |
| Launch the “Physicianship Interest Groups” (i.e. develop the curriculum or content; design faculty development, recruitment drives). The stipends for the clinicians would be paid by the University. | This aspect of the program could be given a name e.g. an “Academy”, and this entity could be named in honor of the donor. | gift of $50,000 |
| Endow the “White Coat Ceremony”. | Yes | $80,000 endowment
(Note: the Faculty has a benefactor and currently the ceremony is funded on an annual basis) |
| Support for the Student Community Projects. These are important elements of the program that will promote altruisms and social responsibility on the part of physicians. | Bursaries can be named after the donor(s) or for the project focus (e.g. multiculturalism; woman’s shelter; aboriginal health; mental health; handicapped; suicide prevention; etc.) | $240,000 endowment
(Note: a minimum of 6 bursaries are required; at $40,000 per bursary X 6 = $240,000). Ideally, there should be 10 bursaries. |
| Support Physicianship discussion groups by funding alterations to McIntyre Bldg. | Yes, specific rooms or areas could be given a name e.g. a “commons” and this could carry the name of the donor. | $10,000 gifts |
| Fund Phase 2 of the Ingram & Company proposal; this will allow the Faculty to understand how patients experience today’s doctors and hospitals – and what an “ideal” experience would be from a patient perspective. | No | $150,000 gift |
| Fund Phase 3 of the Ingram & Company proposal; this will permit effective tracking of program effectiveness. | No | $400,000 gift |
| Support Faculty
Development initiatives.
Note: the stipends would be paid for by the University. |
Yes | $10,000 - $20,000 gifts |
| OR | ||
| Endow the
entire “Physicianship: the Physician as Healer and Professional”
curriculum. ** |
A donor could be honored as follows: The “ ____ insert name_____ Program in Physicianship” or The “ ______ insert name ______ Curriculum on Professionalism and Healing”). | Endowment of $5 million |
** The
levels of support indicated in the above table are preliminary estimates;
they have not been reviewed with the Dean or the Alumni and Development
Office. They are presented primarily for the sake of discussion and
to establish the main “bottom-lines”. They will need to be reviewed
and approved by the Dean before any presentations to external agencies
or benefactors. Note: the Physicianship program could be implemented
without an endowed chair; in that case, the total gift could be reduced
to $3 million. This amount would ensure the development of the curriculum
and delivery for a minimum of 3 years. Ideally, if there is no endowed
Chair, additional sums should be secured in an endowment fund so that
future viability is ensured.
“Caring
is a profound act of hope." Terry White
M. References:
The M.D.,C.M. program objectives
are available at: http://www.medicine.mcgill.ca/ugme/curricobjective.htm
The LCME accreditation standards are available at:
http://www.lcme.org/functionslist.htm
1. Report of the survey of McGill University, Faculty of Medicine, LCME and CACMS; May-22-26, 2002: page 3-4.
2. Functions and Structure of a Medical School, Liaison Committee on Medical Education, September 2003.
3. Learning Objectives for Medical Student Education: Guidelines for Medical Schools; Medical Student Objectives Project: AAMC publication, January, 1998.
4. The Clinical Education of Medical Students: Report on Millennium Conferences I & II: AAMC publication.
5. The CanMEDS Project. Canadian Medical Education Project. Royal College of Physicians & Surgeons of Canada, September, 2003.
6. Exit Survey - Class of 2002: MD,CM program, May, 2002: page 40.
7. Imputabilité Médicale et Gouvernance Clinique. Conseil Médical du Québec, September, 2003.
8. Social Accountability: A Vision for Canadian Medical Schools, Publication of Health Canada; 2001: page 1-4.
9. Complementary and Alternative Health Care: The Other Mainstream? Health Canada publication. November, 2003.
10. Coulehan, J., et. al. The Best Lack all Convictions: Biomedical Ethics, Professionalism, and Social Responsibility. Cambridge Quartely. Health Care Ethics. 2003; 12: 21-38.
11. Levinson W. et. al. Physician-Patient Communication – the Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons. JAMA 1997; 277(7):533-559.
12. Michalon M., et al. Physicians as Patients – Substance Use and Psychiatric Illnesses among Medical Trainees and Practitioners: A Professional Predicament. Annals RCPSC 1998, 31(8):379-383.
13. 21st Century: A New Vision for Health Care. Reports from the Teaching and Research Committees, MUHC, July 15, 1997.
14. Cruess SR, Cruess RL. Professionalism: A Contract Between Medicine and Society. CMAJ 2000; 162: 668-669.
15. Kearney M. A Place of Healing: Working with Suffering in Living and Dying. Oxford University Press; 2000.
16. Charon R. Narrative Medicine: A Model for Empathy, Reflection, Profession and Trust. JAMA 2001; 286 (15):1897-1902.
17. Charon R. Narrative and Medicine. NEJM; 350(9): 862-863.
18. Kutz S. et al. Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Acad Med 2003; 78(8): 802-809.
19. Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement. Acad Med 2001; 76(4): 390-393.
20. Phoon C. Must Doctors Still Examine Patients? Perspectives in Biology and Medicine 2000; 43(4): 548-561.
21. Report on Professionalism in Undergraduate Medical Education. Faculty of Medicine. University of Toronto. May, 2000
22. Cassell Eric J. Talking with Patients, Volume 1: The Theory of Doctor-Patient Communication. Cambridge, Massachusetts, MIT Press, 1985.
23. Stern David T.
GSA, AAMC annual meeting, Nov. 2003.
“The physician sees "disease"; the patient feels "illness" (or dis-ease)”.
C. Scriver
O. Appendices
1. Report from the: McGill Working
Group on Professionalism
2. Report from the: McGill Working
Group on Healing & Health Care
3. Report from the: ad hoc
Committee on Evaluation of Physicianship
4. Correspondence related
to the consultation with Dr. Louise Arnold, on strategies for student
evaluation on physicianship
5. Additional recommendations
from Working Group on Professionalism
6. Narrative Medicine
7. Curriculum Schema - current
8. Curriculum Schema - proposed
9. Physicianship Portfolio
10. Clinical Evaluation
Form: modified to include Physicianship
11. Funding
for Community Projects Initiatives
12. Teaching the Clinical
Method, manuscript by Dr. E. Cassell
13. Teaching Communication
Skills: the Bayer-Fetzer Model and the Calgary-Cambridge Guide.
14. Blueprint: teaching
of Physicianship Objectives in various courses (note: this is incomplete)
Appendix 1:
Report of
the Working Group on Professionalism
Appendix 2:
Report of the Working Group
on Healing & Health Care
Appendix 3:
Report of the
ad hoc Committee on Evaluation of Physicianship
Appendix 4:
Consultation with Dr. Louise
Arnold re: Evaluation of Physicianship
Appendix 5:
Additional
Recommendations from the Working Group on Professionalism re:
Evaluation of Physicianship
Appendix 6:
Narrative Medicine
In order to care for patients
physicians need to acknowledge, absorb, interpret, and often act on
the stories (or, more narrowly, the "case histories") of patients.
In order to create a space for healing the physician needs, in addition
to scientific competence, the ability to listen actively to patients,
understand and honor patients’ stories and predicaments, tolerate
ambiguity, and be compelled to act on the patient’s behalf to reduce
suffering. These tasks describe narrative competence. It is not something
new to the practice of medicine. "Good" clinicians, the ones
who are loved by their patients and admired by their colleagues, have
this competence and are able to teach it to others often by their very
presence in the form of positive role-modeling. Rather than a "new"
skill, narrative competence is another way of looking at the complex
interactions that occur between: patient/physician; themselves (self
care); physician/physician; physician/society. Examining these relationships
by looking through a “narrative lens” offers a new way to deconstruct
the elements of relationships and interactions that promote the ideal
of medicine encouraging a practice of medicine that is empathic, reflective,
compassionate, professional, and authentic.
Viewing the professional and healing relationships and interactions of physicians through a narrative lens means examining what people say (i.e. their “stories”) using narrative techniques. These techniques include, but are not limited to, the consideration of these aspects of a story:
mean? Why is this patient representing at this time?
Ref: 16, 17
Appendix 7: Basis of Medicine & Dentistry (BOM/D)
|
||||||||||||||||||||||||||||||||||||
Introduction to Clinical Medicine (ICM)
|
|
|
Practice of Medicine (POM) Clerkship
|
||||||||||||||||||||||||||||||
Back to Basics (BTB)
| September | October | November | December | January | February | March | April |
| Family
Medicine |
Elective
# 3 |
Vacation |
Elective
# 4 |
Seminar Option (Humanities) | Medicine
& Society |
Seminar
Options (3)
(Basic Sciences) |
|
| Ambulatory Medicine/ Communications Plus | |||||||
Appendix 8: Basis of Medicine (BOM)
|
||||||||||||||||||||||||||||||||||||
Introduction to Clinical Medicine (ICM) POM
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Practice of Medicine (POM) Clerkship
|
|||||||||||||||||||||||||||||||||||||||||||||
Back to Basics (BTB)
|
||||||||||||||||||||||||
P-8 P-9
Legend to
new Curriculum Schema
Courses on “The Physician as Healer & Professional” (i.e. these are credit granting courses; registered with the University)
PHP-A: The Physician as Healer & Professional - A
PHP-B: The Physician as Healer & Professional - B
PHP-C: The Physician as Healer & Professional - C
PHP-D: The Physician as Healer & Professional - D
PHP-E:
The Physician as Healer & Professional -
E
Events related to
“The Healer & Professional” (i.e. these do not provide credits;
are not registered as courses)
P-1: Orientation Day Sessions on Professionalism
P-2: Student Wellness Day
P-3: Commemorative Service for Donors of Bodies
P-4: Dr. Joseph Wener-Donning the Healers Habit Ceremony (i.e. the White Coat Ceremony)
P-5: Student Projects Presentation Day (Research and Community Based Projects)
P-6: meetings of Physicianship Discussion groups
P-7: annual Osler Lecture & Banquet
P-8: submission of Physicianship Portfolio
P-9:
Graduation & Convocation ceremonies
Appendix 14:
Template of an educational
blueprint for “physicianship” (including the “clinical method”):
| Unit | Aspect(s) of Physicianship that will be addressed in the unit | Teaching modality and/or assessment strategy that will be used |
| Physician as Healer & Professional - A | ||
| Physician as Healer & Professional - B | ||
| Physician as Healer & Professional - C | ||
| Physician as Healer & Professional - D | ||
| Physician as Healer & Professional - E | ||
| BOM Unit 1 | Ethics; Responsibility to society; Conflict of Interest | a 2-hour small group on: Ethics & Biotechnology |
| BOM Unit 2 | ||
| BOM Unit 3 | ||
| BOM Unit 4 | ||
| BOM Unit 5 | ||
| BOM Unit 6 | ||
| BOM Unit 7 | ||
| BOM Unit 8 | Genetics:
counseling, role modeling,
Psychiatry: role modeling Pharmacology: compliance; ethics in dealing with pharmaceutical companies Pathology: role modeling with respect to issue of autopsies; interdisciplinary communication |
|
| ICM - Medicine | ||
| ICM - Family Medicine | ||
| ICM - Surgery | obtaining
informed consent
etiquette in the OR proper draping of the patient |
|
| ICM - Emergency Medicine | ||
| POM - Medicine | ||
| POM - Surgery | ||
| POM - Psychiatry | keeping professional boundaries | |
| POM - Pediatrics | ||
| POM - Geriatric Medicine | ||
| POM - Family Medicine | ||
| POM - Ob/Gyn | ||
| POM - Electives | ||
| BtB – Humanities Option | ||
| BtB – Basics Science Option | ||
| BtB – Medicine & Society | ||
| BtB – Public Health | ||
| BtB – Molecular Biology |
Appendix
9:
Physicianship
Portfolio
Goal of the portfolio:
it is hoped that it will stimulate self-perception & reflection
on the student’s personal transformation from “laymanship to
physicianship” and that it will foster an on-going appreciation
of issues related to professionalism. It is anticipated that the review
of the portfolio with a faculty member and the discussions that they
may trigger, in the context of physicianship discussion groups, will
promote reflection.
Structure: The
portfolio will be used for formative purposes. It will be owned by the
student; it will not be entered in the student’s academic file. All
students would be required to complete it and submission will be a requirement
for promotion and graduation. This requirement will be included in the
University calendar, the program’s promotion regulations as well as
in the Code of Conduct for the M.D.,C.M. program.
Content
items: Ordinarily the self-reflections would be submitted
in text form and would be quite brief (approx.1 page or less in length).
Although there will be no faculty imposed “floor or ceiling” on
the quantity of de novo materials submitted, it is anticipated
that most portfolios, developed over 4 years, would be approximately
10 (+/- 2) pages in length; this is excluding the materials previously
generated for other purposes e.g. autobiographical letters. In other
words, the portfolio would be quite “lean”. This is in keeping with
the aim that it not be an overly onerous task for students to produce
and faculty to read.
Review of Portfolios:
They would be reviewed annually, on an individual basis, by the physicianship
discussion group leader.
Evaluation: The quality of the portfolio would not be subject to assessment. However, the group leader would be required to complete a brief “status report” and submit to the Associate Dean, Medical Education, by the end of third year (i.e. end of clerkship) on the student’s:
(Hopefully a web-based system
could be put in place for the group leaders to submit their reports).
Role of Portfolio in the
Evaluation of Physicianship (and professionalism):
The status report would be
one of several items used by the Associate Dean in completing the section
on Professionalism in the Medical Student Performance Evaluation (MSPE)
document. The structure of the section on Professionalism in the MSPE
document has not yet been finalized. It is likely that it would include
several sections. A possible framework is as follows:
| Student
name: MK
Date: October, 2010 Based on the following measures, MK {meets/does not meet/exceeds} our expectations for professionalism:
Some narrative comments provided by supervisors on professional behaviours include:
__________________________________________________________________________ Signed, ______________________ M.D., Associate Dean
|
Ref: (23)
Note: this approach to the
Dean’s letter can be introduced even in the absence of a longitudinal
approach to the evaluation of professional behaviours
Example of a portfolio:
This portfolio consists of
at least 8 items, 6 of the items to be submitted by the end of the core
clerkships.
| Content items | Timing of entry | Required vs. Optional |
| the autobiographical letter used for medical school application | during orientation week | required |
| an update to the autobiographical letter - with comments on “have I achieved my original goals?”, “personal goals I hold currently” and “personal meaning of becoming an MD within a few weeks” | within one month of graduation | required |
the description
of an event illustrating positive and/or negative role-modeling
of one or more of the following professional attributes (as demonstrated
by myself, a fellow-student, a clinical supervisor or other member of
the health care team):
(Note: for purposes of the portfolio, avoid identifying the individuals, courses, services or institutions involved). |
by the end of the core clerkships | required |
| a copy of
the reflection that was read out by the student at the Commemorative
Service for Donors of Bodies
OR a reflection on the white coat ceremony |
by end of first
year ………………... within one month of the ceremony |
required |
A personal
statement on how any of the following extracurricular or elective activity
will impact on future career:
|
at any time | required |
| Options (personal reflections) | ||
| one or two reflection(s) extracted directly from the parallel chart | at any time | Student must submit at least four reflections; at least three of them must be submitted and reviewed by the faculty leader by the end of core clerkships |
| the description of a “healing moment” experienced or observed | at any time | |
reflection(s)
following any of these clinical situations
|
at any time | |
| a reflection on how culture (defined broadly) has impacted on the care of a patient in whose care I was involved (e.g. taking an interview via an interpreter) | at any time | |
| a reflection on the advantages or disadvantages of the Quebec health care system | at any time | |
| a response to any unexpected reaction (e.g. fainting in the O.R.) | at any time | |
| a reflection on any sudden change in career plans and the underlying reasons for this | at any time | |
| a description of a clinical situation where “I was readily able to demonstrate empathy” and/or one where, “I had difficulties in demonstrating empathy” | at any time | |
| a reaction to illness: personal, family, or vicarious (e.g. in a film, newspaper, book, etc.) | at any time | |
Note: the items required in
the portfolio may have be modified somewhat for students in the MD/MBA
and MD/PhD programs (e.g. someone in the MD/PhD program may be asked
to reflect on research ethics, experience with IRB, grant application
process, etc.).
Appendix
10:
Clinical Evaluation Form: modified to include Physicianship.
An example - for discussion:
| U | BE | ME | EE | S | |
| knowledge basic sciences | |||||
| knowledge clinical sciences | |||||
| medical interview | |||||
| physical examination | |||||
| problem identification | |||||
| clinical judgment | |||||
| use of technology | |||||
| use of therapeutics | |||||
| communication skills | |||||
| interpersonal skills | |||||
| organizational skills | |||||
| technical skills | |||||
| Narrative: |
|||||
|
Physicianship:
Behaviours & Attitudes |
U | ME |
| caring and compassion | ||
| integrity & honesty | ||
| reliability | ||
| respect | ||
| self-critique & insight | ||
| commitment | ||
| professional responsibilities | ||
| Global | ||
| Narrative: | ||
Appendix
11:
Funding for Community Projects
Initiatives
Appendix
12:
“Teaching the Clinical Method”
manuscript by
Dr. Eric Cassell
Appendix
13:
Teaching Communication Skills:
the Bayer-Fetzer Model and the Calgary-Cambridge Guide.
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