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 fouryear 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-onone 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
Rationale for Change
C.1 – C. 3
5-6
Vision and Scope of Change
D.1 – D.3
7-9
Content and Methods of Teaching – Recommendations
E.1 – E.23
11-20
Student Assessment on Physicianship: General Recommendations
F.1 – F.6
21
Student Assessment on Physicianship: Specific Recommendations
G.1 – G.12
22-24
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
C.
D.
E.
F.
G.
H.
K.
Miscellaneous Issues
- timeline
- role of the McGill Centre for Medical Education
- role of the McGill University Skills Centre
- unresolved issues
31-34
L.
Opportunities for Fund Raising
35-37
M.
References
38-39
N.
Signatures
O.
Appendices # 1 -14
Abbreviations used in the report
AAMC =
ACLS =
ALDO =
American Association of Medical Colleges
Advanced Cardiac Life Saving (a course)
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
1
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
2
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.
3
Task-Force Membership:
Name
Dr. Donald Boudreau (Chair)
Dr. Yvonne Steinert (Ex-officio)
Ms. Janet Butt (Secretary)
Dr. Manuel Borod
Dr. James Brawer
Mr. Matthew Cesari
Ms. Mylène Dandavino
Dr. Anna Derossis
Dr. Carolyn Ells
Dr. Sharon Johnston
Dr. Marc Laporta
Dr. Stephen Liben
Dr. Wendy MacDonald
Dr. Joyce Pickering
Dr. Maureen Rappaport
Dr. John Setrakian
Dr. Charles Scriver
Dr. Simon Young
Associate Dean, Medical Education
Associate Dean, Faculty Development;
Associate Director, Centre for Medical Education
Student Records Officer
Internal Medicine
Basic Science
Student Representative
Student Representative
Surgery
Bioethics
Resident Representative
Psychiatry
Pediatrics
Pediatrics
Internal Medicine
Family Medicine
Internal Medicine
Pediatrics
Basic Science
Dr. Louise Arnold
Dr. Eric Cassell
Dr. Richard Cruess
Dr. Sylvia Cruess
Dr. Michael Kearney
Dr. Balfour Mount
Consultants
University of Missouri – Kansas City
Weill Medical College of Cornell University
Centre for Medical Education, McGill Univ.
Centre for Medical Education, McGill Univ.
University of California, San Diego
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
4
C.
Rationale for Change
C.1
Pedagogic 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
Medical School » require that “behavioural subjects, medical ethics, human
values, and cultural beliefs be included in the curriculum” (ED-10; ED-19; ED21; 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 third and 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.
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
C.2

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

Professional 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
5
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
C.3

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


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)
Opportunities 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
6
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
 The admissions process emphasizes academic excellence and attempts to assess
the following personal characteristics: leadership skills; commitment; reliability
and responsibility; ability to communicate and relate; originality and creativity;
capacity for growth
Model of Graduate
 We recruit, and educate, from the perspective that the graduate of the program
aspires to become a practicing physician.
 We educate with the optic that the student will be “undifferentiated” at the time of
graduation (i.e. we do not offer various “streams” within the program).
Educational Principles and Educational Methods
 We adhere to the premise that the fundamental sciences and scientific
methodology are the pillars of medical knowledge.
 The program and courses are based on clearly defined objectives.
 The first phase of the program is structured so as to favor horizontal and vertical
integration of basic and clinical sciences.
 We utilize methodologies that promote active learning (e.g. small-group formats)
and enhance professionalism (e.g. teach anatomy using cadaver dissection).
Program Content
 We promote and provide opportunities for students to contribute to the creation of
new knowledge.
 We promote and provide opportunities for inquiry and reflection on the nature of
knowledge, the practice of medicine, the context of practice, medical judgment,
and the history of medicine.
 We sequence the program as follows: normal structure and function; followed by
abnormal structure and function and disease; followed by clinical experience,
followed by a period of reflection and review.
 The program is sensitive to student needs with respect to the residency matching
process and provides appropriate counseling; however, we do not permit major
interruptions or disruptions to a student’s educational experience or modify the
core elements of the program to facilitate entry into any specific residency
program.
Locus of Learning
 We operate on the assumption that medical education is most effective if the locus
of teaching and learning is with the patient. Patient-doctor encounters take place
in many venues (including the home, ambulatory settings and the hospital).
Furthermore, the goal is to teach with real patients as opposed to Standardized
Patients (SPs).
Student and Program Evaluation
 We utilize a variety of methodologies for student evaluation and aim for an
appropriate match of evaluation method to objective.
7
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
 The admissions process emphasizes academic excellence and attempts to assess
the following personal characteristics: leadership skills; commitment; reliability
and responsibility; ability to communicate and relate; originality and creativity;
capacity for growth; and altruism. The program values diversity and students with
a wide range of educational backgrounds and interests will be encouraged to
apply.
Model of Graduate
 We recruit, and educate, from the perspective that the graduate of the program
aspires to become a practicing physician.
 We educate with the optic that the student will be “undifferentiated” at the time of
graduation (i.e. we do not offer various “streams” within the program).
Educational Principles and Educational Methods
 We adhere to the premise that the fundamental sciences and scientific
methodology are the pillars of medical knowledge.
 The program and courses will be based on clearly defined objectives
 A defining theme (leitmotif) for the curriculum will be introduced and all rotationspecific objectives (including clerkships) will incorporate the broader program
objectives.
 The leitmotif will be “The Physician as a Professional & Healer” (also referred
to as physicianship). The professional role includes within it the concept of
competence; this is tightly linked to scientific knowledge. These unique, yet
complementary roles can be described with specific knowledge, skills, attitudes
and behaviours. They are listed in the M.D.,C.M. program objectives.
 The first phase of the program is structured so as to favor horizontal and vertical
integration of basic and clinical sciences.
 We utilize methodologies that promote active learning (e.g. small-group formats)
and enhance professionalism (e.g. teach anatomy using cadaver dissection).
 While we will make use of standardized patients and/or models to teach and
evaluate basic clinical skills, primarily for summative purposes, we will continue
to prioritize the teaching of these skills and the provision of formative feedback in
the context of real patient encounters.
 We will use narrative medicine techniques to promote empathy and reflection (16,
17) (see appendix 6).
Program Content
 We promote and provide opportunities for students to contribute to the creation of
new knowledge.
 We promote and provide opportunities for inquiry and reflection on the nature of
knowledge, the practice of medicine, the context of practice, medical judgment,
and the history of medicine.
 We sequence the program as follows: normal structure and function; followed by
abnormal structure and function and disease; followed by clinical experience,
8
followed by a period of reflection and review.
 The cognitive basis of professionalism and healing will be taught explicitly.
 A framework of the “clinical method” will be used to teach the skills of the
physician as professional and healer.
 A key component of the clinical method is patient-physician interactions; the
program will teach communication skills using a formal, intentional, systematic
and longitudinal approach such as the Bayer-Fetzer model or the CalgaryCambridge Guide. One of these models may be subject to some modifications in
order to be better adapted to local contexts.
 The clinical method includes observation skills; the program will teach
observation skills explicitly.
 The clinical method includes the performing of a detailed physical examination.
There are several motives for teaching the skill of the traditional physical; these
include: recognizing the normal; recognizing the abnormal; appreciation of
variations among individuals; contributing to the patient-physician relationship.
 Another feature of the clinical method is self-reflection; the program will
incorporate narrative medicine, portfolios, discussion groups and “immerse and
retreat” strategies during clinical rotations (i.e. clinical experience followed by
mandatory reflective exercises), in order to promote the development of a selfreflective physician.
 We will promote and provide opportunities for students to contribute to
community service in an effort to nurture social accountability.
 The program is sensitive to student needs with respect to the residency matching
process and provides appropriate counseling; however, we do not permit major
interruptions or disruptions to a student’s educational experience or modify the
core elements of the program to facilitate entry into any specific residency
program.
Locus of Learning
 We operate on the assumption that medical education is most effective if the locus
of teaching and learning is with the patient. Patient-doctor encounters take place
in many venues (including the home, ambulatory settings and the hospital).
Teaching in clinical settings will remain dominant.
Student and Program Evaluation
 We utilize a variety of methodologies for student evaluation and aim for an
appropriate match of evaluation method to objective.
We should take care not to make intellect our god; it has, of course, powerful
muscles, but no personality.”
Albert Einstein
9
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
10
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
11
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 selfreflection, 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).
12
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 extracurricular 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 directors of clinical rotations (ICM and POM) be invited very early on to
provide their input and suggestions
13


each clerkship be required to focus on a specific aspect of the CS model
each rotation that evaluates clinical skills be required to modify their evaluation
form so that it is congruent with the underlying model
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:
 additional reviews of cases of academic failures over the past decade be
conducted with the aim of identifying any aspects of the selection process that
may benefit from revisions (e.g. % allocation to specific cohorts; interviews, etc.)
 the admissions office communicate, to prospective applicants (in printed
materials, recruitment events, interviews, etc.) the program’s renewed emphasis
on physicianship
 the admissions office and selection process reaffirm the importance of altruism
and service to others in prospective candidates and that this can be demonstrated
by a variety of means (of which volunteer service in health care institutions is but
one example)
 students with non-science backgrounds (e.g. Social Sciences and the Humanities)
be encouraged to apply to McGill’s program
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.
14
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
15
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:
 an introductory course, called The “Physician as Healer and Professional – C”. It
would focus on two aspects of the clinical method: the physical examination
(including the mental status and neurological) and the logic of medicine. It would
cover much of the content previously covered in ICS, Evidence Based Medicine
and elements of the Clinical Process modules of IHP (offered by Dr. Setrakian).
There would be additional emphasis on the nature of knowledge & uncertainty.
 a 10-week block, with the Department of Medicine as the “proposing”
department. It would focus on Internal Medicine but also offer some content in
oncology and pediatrics. It would include a longitudinal Family Medicine clinic
experience (1/2 day per week). Should we call it: “ICM – Doctorem Medicinae”?
 a 10-week block with the Departments of Surgery and Anesthesia as the
“proposing” departments. It would focus on Surgery, surgical skills and perioperative care. It would offer some content in Radiology, Radiation Oncology and
Obstetrics & Gynecology. It would include a longitudinal experience in
Emergency Medicine (10 ER shifts). Should we call it: “ICM – Chirurgiae
Magistratum”?
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”.
16
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 MCCPart 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
17
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:
PP I
PP II
PP III
PP IV
PP V
Current
Units included
Start & end dates
BOM 1-6; ITP
Aug - June
BOM 7,8; ITPM
Sept- Dec
ICM*
Jan - Sept
POM
Sept- Dec
BtB
Jan - May
Proposed
Units included
Start & end dates
BOM 1-6; PHP-A
Aug - June
BOM 7,8; PHP-B
Sept - Dec
ICM (includes PHP-C)
Jan - June
POM (includes PHP-D) Aug - Dec
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 2 nd
year. The current ICM elective is therefore moved to the POM component.
18
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.
19
Summary:
specific recommendations - curriculum content on physicianship:
develop a series of five courses on the “Physician as Healer & Professional”
(PHP)
introduce “Physicianship Discussion Groups” for students, in all four years
introduce “Physicianship Portfolios”
develop a longitudinal assessment of student competence in “physicianship”
develop Community based education projects (akin to research bursary program)
renew teaching of the “Clinical Method” & develop a unique McGill approach
adopt a formal and explicit approach to the teaching of communication skills
review candidate recruitment and admissions in light of curricular modifications
modify program orientation content
mandate introduction of “physicianship” content in each of BOM units
retire ITP/ITPM courses; reformat as PHP-A and PHP-B
restructure ICM component
teach aspects of physical examination earlier; retire ICS and reformat as PHP-C
restructure Professional Skills unit; retire Medical Ethics & Health Law
introduce a skills-based ICM exit examination; it should include an OSCE
develop a new course called PHP-D (a reframed “Introduction to POM)
assign students to clerkship sequences on a random basis
develop an educational blueprint for program
retire “Communications Plus”; rename it PHP-E
review new promotion regulations and obtain legal input
modify definitions and timing of Promotion Periods
modify the clinical case construct used by the electronic curriculum
a parallel recommendation:
introduce a mandatory rural rotation in Family Medicine
E.1
E.2
E.3
E.4
E.5
E.6
E.7
E.8
E.9
E.10
E.11
E.12
E.13
E.14
E.15
E.16
E.17
E.18
E.19
E.20
E.21
E.22
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
20
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 selfimprovement) 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:
a) Impact on Promotion and Graduation - significant breaches in physicianship
may, when specified conditions are met, result in academic delay or dismissal
b) Impact on Residency Application - since official notification will be made on the
Dean’s Letter, theoretically there could be negative or positive repercussions.
c) Impact on Prize and Award Decisions - the longitudinal evaluation will be used
by the CSPCO and contribute to the decision making process. It may also be a
factor considered in the selection process for membership in AOA or GHHS.
F.5
Underlying Evaluation Principles and Strategies:
a) A variety of evaluation methods will be used, with the method appropriate to the
objective. Knowledge will ordinarily be assessed using written examinations (e.g.
MCQs, SAQs, OSCE post-encounter probes); skills will ordinarily be assessed
using OSCEs, self-assessments using SPs or clinical supervisor-generated
evaluations; behaviours will ordinarily be assessed using supervisor-generated
evaluations, critical incident reports, and (once validated) the P-MEX.
b) The principle of independent assessments (i.e. no “forward-feeding” from one
course or supervisor to another) will be respected.
c) Principles of natural justice will be followed in any adjudication proceedings.
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”.
21
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)
22
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.
23
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:
 Teachers require “explicit” rather than “implicit” knowledge of the roles of the
physician as healer and professional.
 Teachers must possess, demonstrate and be able to teach physicianship.
 Teachers may already believe they are skilled as healers and professionals, and
that teaching this content (knowledge, attitude and skills) is intuitive.
 Physicianship must be evaluated.
 Physicianship must be valued by the organization/culture.
24
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:
 workshops or seminars (both site/discipline specific and centrally based)
 short courses
 one-on-one consultations (e.g. physicianship “detailing”)
 role modeling and mentorship
 peer coaching
 on-line learning
 self-directed initiatives
 faculty retreats and/or “think tanks”
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:
 at an individual/departmental level:
- 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
 at a program level:
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.
 at a systems level:
collaborating in initiatives aimed at promoting and supporting the
educational mission e.g. faculty orientation and mentoring, support for
research in medical education, etc.
25
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:
 The MEAP project, supported by the Center for Educational Outcomes, C. Everett
Koop Institute, Dartmouth College, will permit the monitoring of the education
process, with respect to the evolution of attitudes and values.

Ingram & Company will assist by identifying the student’s perspective i.e. the
understanding of expectations, attitudes, perceptions, motivations and feelings
about the curriculum, educational experience and physicianship. They will do so
via six focus groups: two with students in mid-program (Class of 2006), two with
graduating students (Class of 2004) and two with incoming students (Class of
2008). They will then make recommendations on metrics to measure impact of
curricular change. This same company will also develop an understanding of the
current curriculum, educational experience and physicianship from the point of
view of educators. They will do so via interviews with a minimum of 10 clinical
teachers in the faculty. The cost of identifying the learner and teacher
perspectives has already been covered with a grant from the Max Bell foundation.
This work will be accomplished in May- August, 2004.
Ref: Proposal by Ingram & Company, March 12, 2004

Knowledge of the patient perspective (the patient experience) is also considered
important. The program will benefit from gaining an understanding of the current
experience of patients receiving care at McGill affiliated hospitals and by McGill
trained students. We also need to know the “ideal” patient experience - from their
point of view. This will help to establish “McGill-ness” i.e. the set of qualities and
values that permeate the patient experience and medical education. Funds to carry
out this component of the Ingram & Company proposal have not yet been
secured. It is hoped that each of the McGill affiliated hospitals may contribute to
this study. Robust knowledge of student, teacher and patient perspectives will
help to establish appropriate benchmarks, measure change and create feedback
loops.
Ref: Proposal by Ingram & Company, March 12, 2004

The Centre for Medical Education will participate in designing impact studies.

The Skills Center will include a research component - focused on “best-practice”.
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
26
J.
Resources Required for Implementation
J.1
Director of “M.D.,C.M. Physicianship Program”:
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:
 organizes the program orientation session on professionalism
 chairs the coordinating committee for the PHP-A,B,C,D,E courses
 orients the students to the “Physicianship Portfolio”, the “Physicianship
discussion groups”, the Code of Conduct, the Physicianship program and
evaluation system
 organizes the White Coat ceremony
 orients the members of the “Physicianship Interest Group” to their responsibilities
 coordinates the collection of the “Physicianship Portfolio” status report and
submits to Associate Dean, Medical Education
 assists the Unit Chairs in planning and delivering the physicianship related
activities within their units
 assists unit chairs and clerkship directors in developing physicianship related
items for in-unit exams and the ICM- exit exam
 assists Associate Dean in any curricular outcome monitoring and/or research
initiatives related to physicianship
 assists the Dean and Faculty in fund-raising and PR initiatives related to
physicianship
Costs:
 remuneration for director; this would require approximately $40,000
 additional clerical support; this would require approximately $35,000
Total cost:
approx. $75,000 per annum
27
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
attendance at an orientation session, at the annual “de-briefing”
session, and at selected Faculty Development workshops
lead a physicianship discussion group (3 meetings per yr)
review student’s physicianship portfolio annually and
submit the portfolio status report in student’s 3rd year
attend the Student Project Presentation Day and/or
White Coat Ceremony
participate in at least two small group sessions (per year) of the
physicianship courses
act as group leaders in the ITP & ITPM small group program
participate as an “ICS” instructor
A
B
X
X
C
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Benefits for interest group members:
 a stipend (level A = $2,000/yr; level B = $4,000/yr; level C = $6,000/yr)
 belong to a group of colleagues with similar interests
 CME credits; entry in teaching dossier
 opportunity to learn about the undergraduate medical program (philosophy,
structure, education methods, etc.) and to meet medical students in an informal
environment
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
28
J.3
Academic Coordinator of Student Community Projects:
This individual, a faculty member, would oversee the (elective/extra-curricular) student
community projects.
Responsibilities:
 organize an information session for students
 liaise with community organizations
 assist students in developing appropriate and feasible projects
 receive & review application for student bursaries; select recipients
 ensure that there has been review of project with the community organization’s
leadership and that the “deliverables” were indeed delivered
 assist the Associate Dean, Research in organizing the annual Student Projects
Presentation Day
 assist the Dean and Development Officers in fund raising for these bursaries
 liaise with any external funding agency (e.g. Pfizer Medical Humanities Initiative)
Costs:
 coordinator’s stipend (approx. $5,000 per annum)
 student bursaries (approx. $12,000 per annum – as a minimum)
Total cost:
approx. $17,000 (including student bursaries)
J.4
Physical Resources:








a “Physicianship Interest Group” lounge or meeting area (i.e. a “commons”),
preferably at the McIntyre, where members could meet as a group or meet with
students. This lounge area might house a cabinet containing reading materials
related to physicianship and a computer
office for the Director of Physicianship Program (preferably near the UGME area)
office space for extra clerical staff to support the Physicianship Program
office space (shared) for physicianship core faculty development trainers
office space for research assistant(s)
office materials and computer hardware and software for Director and staff
Web-based programs for transmission of portfolio status report and physicianship
evaluation
audiovisual equipment (as yet undefined) in order to teach communication skills
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.
29
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:
 phase 1: understanding of the learner and teacher perspectives
 phase 2: understanding the patient perspective and “ideal” patient experience
 phase 3: establishing of performance benchmarks over the 5 year period of
implementation
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
a “core group” of physicianship Facdev trainers
stipends for “peer coaches”
clerical support for this initiative
additional financial support for the Associate Dean
and “a physicianship core group” director
costs attributable to specific Facdev workshops,
courses, seminars, consultations, etc.
Estimated cost
$10,000 per year X 6 = $60,000
$30,000 per year
$30,000 per year
$20,000 per year
$20,000 per year
Total cost:
approx. $160,000 per year (for a minimum of two years) and $100,000 per year thereafter
30
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
Task Force report is delivered to Dean, Deanery Council and M.D.,C.M.
Curriculum Committee.
Feedback to Task Force report is solicited.
Phase 1 of Ingram & Company project (i.e. understanding the students’
and teachers’ perspective on curriculum, educational experience and
physicianship) is carried out.
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”.
Dean and Associate Dean meet with potential donors.
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.
Faculty Retreat.
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.
31
Dates
March 2004
April – July, 2004
April – Aug., 2004
May 2004
as soon as possible
July - Aug., 2004
Sept. 2004
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
Dean informs LCME and CACMS of impending program modifications
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:
1. Communication Skills Program
2. Creating new clinical evaluation forms
3. Portfolio
4. Discussion Groups
5. Clinical Method
It is hoped that many members of the Task Force will agree to continue
working on selected work groups.
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.
Phase 2 of Ingram and Company proposal (understanding the patient
perspective) is carried out; report is delivered to Faculty in August,
2005.
Oct. 2004
Oct. 2004
Oct. 2004 – July 05
Oct. 2004 – July 05
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
Opening of Skills Centre
Roll-out of PHP-B
Roll-out of Community Based Projects
Roll-out of PHP-C
Roll-out of new ICM component
32
Aug. 2005
Fall of 2005
Aug. 2006
Jan. 2007
Roll-out of ICM exit exam
Self-study task-force is appointed by Dean, in preparation for LCME
“Accreditation-2008”
Roll-out of PHP-D
Implementation of mandatory rural rotation in Family Medicine in the
Back to Basics component
LCME accreditation survey visit
Roll-out of PHP-E
First class to have completed the revised curriculum graduates.
Formal review by Faculty
Jan. 2007
Aug. 2007
Jan. 2008 – May
2008
Spring 2008
Jan. 2009
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 “groupthink” 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.
33
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:








A detailed course description for the series of PHP courses will be required. The
ITP/ITPM coordinating committee will be asked to propose a structure for PHPA, B, E and will have input into PHP-C and D. The Undergraduate Medical
Education Committee will be asked to propose a structure for PHP-C. The Faculty
working group on Healing & Health Care has set up a FWG:H Curriculum
Revision Subcommittee; it will be asked to propose course content for PHP-D.
The faculty working group on Professionalism, Dept of Social Studies of
Medicine and the Biomedical Ethics Unit will be invited to all planning meetings.
The interface of the physicianship discussion groups with the current ITP small
group program will need to be clarified.
The details regarding the list of required and optional content items for the
Physicianship Portfolio will need to be finalized.
The educational blueprint on physicianship, for units other than the PHP courses,
will need to be completed.
The proposed student assessment protocols will need to be formally vetted with
the university legal office.
There are two pilot projects currently underway in the program, the results of
which will need to be considered:
- the Study of Narrative Medicine & Group Process (in ICM)
(Dr. B. Mount and Dr. T. Hutchinson)
- the pilot use of the Physicianship Mini-Evaluation Exercises (P-MEX):
(Dr. R. Cruess, Dr. S. Cruess, Dr. Y. Steinert, Dr. S. Ginsberg,
Dr. J. Herold McIlroy)
The role of the Postgraduate office and residency programs, particularly in the
traditional clerkship disciplines, has not yet been addressed.
The details of the communication skills program need to be finalized (19, 22).
34
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
Equip examination rooms in Honor the donor by naming
the Skills Centre.
the room.
Purchase simulators for the
Skills Centre.
Equip the Simulated
Apartment
Equip the lounge area for
SP’s
Yes
Minimum support
$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.
$50,000 to $500,000 gifts
Yes
$50,000 gift
Yes
$10,000 gift
35
Support a specific element
of the communication skills
curriculum (e.g. “breaking
bad news”, communicating
with an interpreter: etc.).
Endow the Skills Centre
facility*
Yes, a group or “guild” of
actors could be created in
support of specific
objectives.
OR
Name the facility after the
donor
$20,000 gift
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
Endow a chair in “The
Clinical Method” or
“Clinical Education” or
“Physicianship”.
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.
Endow the “White Coat
Ceremony”.
Naming potential
Named Chair
Minimum support
Endowment of $2 million
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
Yes
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.
Support Physicianship
discussion groups by
funding alterations to
McIntyre Bldg.
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.)
Yes, specific rooms or areas
could be given a name e.g. a
“commons” and this could
carry the name of the donor.
$80,000 endowment
(Note: the Faculty has a
benefactor and currently
the ceremony is funded on
an annual basis)
$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.
36
$10,000 gifts
Fund Phase 2 of the Ingram No
& 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.
Fund Phase 3 of the Ingram No
& Company proposal; this
will permit effective
tracking of program
effectiveness.
Support Faculty
Yes
Development initiatives.
Note: the stipends would be
paid for by the University.
Endow the entire
“Physicianship: the
Physician as Healer and
Professional”
curriculum. **
$150,000 gift
$400,000 gift
$10,000 - $20,000 gifts
OR
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."
37
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Report of the survey of McGill University, Faculty of Medicine, LCME and
CACMS; May-22-26, 2002: page 3-4.
Functions and Structure of a Medical School, Liaison Committee on Medical
Education, September 2003.
Learning Objectives for Medical Student Education: Guidelines for Medical
Schools; Medical Student Objectives Project: AAMC publication, January, 1998.
The Clinical Education of Medical Students: Report on Millennium Conferences I
& II: AAMC publication.
The CanMEDS Project. Canadian Medical Education Project. Royal College of
Physicians & Surgeons of Canada, September, 2003.
Exit Survey - Class of 2002: MD,CM program, May, 2002: page 40.
Imputabilité Médicale et Gouvernance Clinique. Conseil Médical du Québec,
September, 2003.
Social Accountability: A Vision for Canadian Medical Schools, Publication of
Health Canada; 2001: page 1-4.
Complementary and Alternative Health Care: The Other Mainstream? Health
Canada publication. November, 2003.
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Kearney M. A Place of Healing: Working with Suffering in Living and Dying.
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Trust. JAMA 2001; 286 (15):1897-1902.
Charon R. Narrative and Medicine. NEJM; 350(9): 862-863.
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Enhancing the Calgary-Cambridge Guides. Acad Med 2003; 78(8): 802-809.
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Essential Elements of Communication in Medical Encounters: The Kalamazoo
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Phoon C. Must Doctors Still Examine Patients? Perspectives in Biology and
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Cassell Eric J. Talking with Patients, Volume 1: The Theory of Doctor-Patient
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Stern David T. GSA, AAMC annual meeting, Nov. 2003.
“The physician sees "disease"; the patient feels "illness" (or dis-ease)”.
C. Scriver
39
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 CalgaryCambridge 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:
 Context: What is the context of the storyteller (patient) in terms of economic
status, gender, social class, ethnicity, and religion? What is the temporal context
i.e. how did the story get from here to there? Why did the storyteller choose a
backward-looking story (an explanation of how they got to the present) versus a
forward-looking story (that may guide the best way to act in the future)?
 Voice: this relates to agency and motivation; it is attached to a person and is
deliberate and personal. What is the point of view of the voice and why was it
chosen and what does it mean? Is the voice active or passive? What does it mean
when the patient is given the label of "a poor historian"? How do physicians
translate the voice of the patient into a chart entry and what does it mean?
 Character: Is the character falling into an archetype of a hero, a villain, a victim?
Why have these characters been chosen and what does it mean to the storyteller
(patient)? For example, have they always seen themselves as a victim? How do
they see their physician: as hero, friend, parent, or some combination?
 Time: What is the temporal sequence, why was it chosen and what does it
mean? Why is this patient representing at this time?
 Plot: Is the plot set in a heroic mode narrative wherein, after many difficult
battles, a "victory" is to be attained (e.g. a cure)? Or rather, is the plot one of a
journey where much of value is gained along the way (a quest narrative)? Or, is
the plot difficult to follow and un-nerving to listen to (a chaotic narrative)?
 What is the listener’s response and why?
Ref: 16, 17
Appendix 7:
Basis of Medicine & Dentistry (BOM/D)
September
Molecules,
Cells &
Tissues
October
November
Gas, Fluids & Electrolytes
(4 wks)
(9 wks)
December
Life Cycle
January
February
Endocrinology,
Metabolism & Nutrition
(3 wks)
March
Musculoskeletal &
Blood
April
May
Nervous System & Special
Senses
(4 wks)
(8 wks)
(7 wks)
June
Host
Defense &
Host
Parasite
(5 wks)
July
August
Vacation/Research
ITP
Introduction to Clinical Medicine (ICM)
September
Host
Defense &
Host
Parasite
(2 wks)
October
November
Pathobiology, Treatment &
Prevention of Disease
December
(14 wks)
ITPM
January
Professional
Skills:
ICS
Ethics & Law
EBM
(BCLS)
(4 wks)
February
March
Intro to Internal
Medicine (IIM)
(7 wks)
April
May
June
Intro to Surgery/
D. Intro to
Anesthesia/
P. Emergency
Radiology/Ophthalmology & Med/
H. Neurology/
P. Oncology
Family Medicine
(7 wks)
(7 wks)
July
August
Elective
#1
Vacation /
Research
(4 wks)
Practice of Medicine (POM) Clerkship
September
Intro to
Psychiatry/
Pediatrics/
Ob & Gyn/
Hosp Pract
October
November
Pediatrics
December
Obstetrics &
Gynecology
January
February
Surgery
March
April
Psychiatry
Back to Basics (BTB)
September
Family
Medicine
October
Elective
#3
November
Vacation
December
Elective
#4
January
Seminar
Option
(Humanities)
February
Medicine &
Society
March
April
Seminar Options (3)
(Basic Sciences)
Ambulatory Medicine/
Communications Plus
May
June
Internal Medicine
July
August
Elective
#2
Geriatric
Medicine
Appendix 8:
September
Molecules,
Cells &
Tissues
P-1
Basis of Medicine (BOM)
October
November
Gas, Fluids & Electrolytes
December
Life Cycle
January
February
Endocrinology,
Metabolism & Nutrition
March
Musculoskeletal &
Blood
April
May
Nervous System & Special
Senses
P-2
PHP-A (Patient-Physician Relationship; Professionalism; Ethics; Cultural Competence; Observational Skills)
June
Host
Defense &
Host
Parasite
P-3
POM
Introduction to Clinical Medicine (ICM)
September
Host
Defense &
Host
Parasite
October
November
December
Pathobiology, Treatment &
Prevention of Disease
P-4
January
PHP-C
(Physical
Exam; Logic
of Medicine)
July
August
Vacation or
Research or
Community Project
February
March
April
ICM-Medicine and related
disciplines
Family Medicine
May
June
IMC-Surgery and related
disciplines
Emergency Medicine
July
Elective
#1
August
Vacation or
Research or
Community
Project
P-5
P-6
PHP-B (Communication Skills; Medical Interview)
Practice of Medicine (POM) Clerkship
September
PHP-D (Healing
Mandate; Patient –
Physician
Relationship)
P-6
October
November
December
Pediatrics
Obstetrics &
Gynecology
January
Surgery
P-7
February
March
April
Psychiatry
May
June
Internal Medicine
P-6
P-6
Back to Basics (BTB)
September
October
November
December
Family
Medicine
Elective
#3
Vacation
Elective
#4
January
February
March
April
Humanities & Social
Basic Science Options; Molecular Biology
Sciences
PHP-E (Communication; ALDO; Professionalism Revisited)
P-8
P-9
July
Elective
#2
August
Geriatric
Medicine
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
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
BOM Unit 2
BOM Unit 3
BOM Unit 4
BOM Unit 5
BOM Unit 6
BOM Unit 7
BOM Unit 8
ICM - Medicine
ICM - Family Medicine
ICM - Surgery
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
obtaining informed consent
Teaching modality and/or assessment
strategy that will be used
a 2-hour small group on: Ethics &
Biotechnology
etiquette in the OR
proper draping of the patient
ICM - Emergency Medicine
POM - Medicine
POM - Surgery
POM - Psychiatry
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
keeping professional boundaries
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:
 attendance at the physicianship discussion groups
 level of participation in groups
 status of portfolio (i.e. % of required/optional entries made)
 timeliness of entries (i.e. deadlines respected or not)
(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:
 knowledge of professionalism (as measured by ………..)
 communications skills that are ….. (as determined by …..)
 no major breaches and no repetitive, non-remediated minor lapses in
professionalism
 respect for our Code of Conduct
(http://www.medicine.mcgill.ca/ugme/standardsbehaviour2.htm)
 enthusiastic participation in our physicianship discussion groups and full and
timely compliance with entries in his/her physicianship portfolio
 the global score on the longitudinal physicianship evaluation report
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
the autobiographical letter used for
medical school application
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”
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):
 altruism
 commitment
 self-regulation
 social justice
 honesty & integrity
(Note: for purposes of the portfolio,
avoid identifying the individuals,
courses, services or institutions
involved).
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
A personal statement on how any of the
following extracurricular or elective
activity will impact on future career:
 application for a MIHI grant
 an elective in the third world
 research or Molson project
 a community project
 involvement in student
governance or McGill Medical
Journal, etc.
Timing of entry
during orientation
week
within one month
of graduation
Required vs. Optional
required
by the end of the
core clerkships
required
by end of first year
required
………………...
within one month
of the ceremony
at any time
required
required
Options (personal reflections)
one or two reflection(s) extracted
directly from the parallel chart
the description of a “healing moment”
experienced or observed
reflection(s) following any of these
clinical situations
 my first patient encounter
 my reaction to the death of a
patient in whose care I was
involved
 a clinical mistake that I made
 a personal triumph that I had in
the clinical sphere
 my reaction to a difficult or
angry patient
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)
a reflection on the advantages or
disadvantages of the Quebec health care
system
a response to any unexpected reaction
(e.g. fainting in the O.R.)
a reflection on any sudden change in
career plans and the underlying reasons
for this
a description of a clinical situation
where “I was readily able to
demonstrate empathy” and/or one
where, “I had difficulties in
demonstrating empathy”
a reaction to illness: personal, family, or
vicarious (e.g. in a film, newspaper,
book, etc.)
at any time
at any time
at any time
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
at any time
at any time
at any time
at any time
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
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
caring and compassion
integrity & honesty
reliability
respect
self-critique & insight
commitment
professional responsibilities
Global
Narrative:
U
ME
EE
S
Appendix 11:
Funding for Community Projects Initiatives
Appendix 12:
“Teaching the Clinical Method”
manuscript by Dr. Eric Cassell
Appendix 13:
Teaching Communication Skills: the BayerFetzer Model and the Calgary-Cambridge Guide.