Communicate the vision
Kotter states that “the real power of a vision is unleashed only when most of those involved in an activity have a common understanding of its goals and direction.”8 (p85) The vision for teaching and evaluating professionalism at McGill was communicated through the support given by the dean and the associate deans. It was also promulgated by another faculty-wide workshop on teaching professionalism that accommodated 65 health care professionals representing the basic sciences and all major medical specialties. This workshop, which was held in December 2000, was designed to highlight the importance of teaching professionalism and to improve such teaching by transmitting core content, discussing effective teaching strategies, and developing an action plan for each department. This workshop resulted in increased buy-in among the educational leaders who participated, and it led to the development of new content experts and an array of educational resources that could be used for teaching purposes. It also led to a number of other activities designed to communicate the vision for change, including educational sessions for residents, hospital grand rounds, departmental workshops, and high-profile activities outside McGill such as peer-reviewed publications and presentations at national and international meetings.
Empower others to act on the vision
Kotter specifically identifies the provision of training as one of the five essential ingredients to empower people to effect change.7 In our context, faculty development has been one of the major vehicles for empowering others to lead the change initiative. Knowledge of the importance of the issues became widely recognized as a result of the think tanks and workshops, during which workable solutions appropriate to McGill’s culture and environment were developed. Methods used in the workshops, which included case vignettes, organizing frameworks for matching content to methods, and opportunities for experiential learning and reflection, empowered our educational leaders and colleagues. In many ways, the faculty development program allowed our faculty members to agree on the cognitive base of professionalism, the attributes and characteristics of the professional, and the behaviors to be encouraged among students, residents and faculty. It also provided us an opportunity to explore further how healing, a concept that is essential to the medical mandate, could be integrated into our teaching program.19 Faculty members came to realize that the cognitive base of professionalism and healing must be communicated to students, and that diverse teaching and evaluation strategies should be used. This reflection and discussion also led to a vision for renewal of the undergraduate medical curriculum based on the dual roles of the physician: professional and healer (see List 2).
Generate short-term wins
Kotter highlights the importance of short-term wins in promoting change, providing reinforcement for the efforts taken, helping to fine-tune the vision and strategies implemented, and building momentum.7,8 In our context, we experienced the following short-term gains:
▪ The design and implementation of small-group teaching sessions on professionalism in the first, second, and fourth years of the undergraduate curriculum
▪ The development of a faculty-wide residency teaching program on professionalism
▪ Departmental grand rounds in local hospitals, reaching out to the departments of medicine, pediatrics, surgery, obstetrics and gynecology, orthopedic surgery, cardiac surgery, thoracic surgery, anesthesia, and emergency medicine
▪ The delivery of site-specific workshops in diverse hospital departments (e.g., anesthesia, medicine, obstetrics/gynecology, ophthalmology, surgery)
Although all of these gains did not directly target the undergraduate curriculum, they did have an impact, as many of our teachers teach both students and residents, and many of our residents teach our students.
Our early efforts to promote the teaching of professionalism also led to the need to focus on the evaluation of professionalism. Although aspects of professionalism were being assessed routinely on in-training evaluations, improvement was needed. Thus, several years after this change initiative started, we held another think tank, this time on evaluating professionalism. It was clear to us that for teaching to be successful, professionalism would need to be evaluated in a more systematic way. Thus, we invited 20 educational leaders and content experts to examine methods of evaluating professionalism and to develop the content and methodology of a workshop in this area. At the time, we realized that the attributes of a physician as professional and healer had to be integrated for evaluations to be comprehensive; we therefore added a definition of healing, including the attributes of the physician as healer, which had been developed and agreed on by a work group on healing (as outlined in List 1 and List 2). The outcome was a detailed plan for a faculty-wide workshop, called Evaluating the Physician as Healer and Professional, in May 2002.
This workshop was attended by 95 faculty members and focused on developing methods for evaluating the physician as healer and professional at the undergraduate and postgraduate levels by defining specific, observable behaviors for each attribute, examining different approaches to evaluating professionalism,26,27,50 and assessing the benefits and limitations of different evaluation methods (e.g., global rating scales; portfolios; critical incidents). Organizing frameworks were also used to guide the identification of desirable and undesirable behaviors, the “matching” of methods to behaviors, and the feasibility of different assessment approaches. This workshop led to a consensus on the need to improve the evaluation of professionalism at McGill, and it resulted in a series of recommendations that were presented to the Faculty of Medicine. According to Kotter, short-term wins usually have three characteristics: they are visible, they are unambiguous, and they are clearly related to the change initiative. In our own setting, these characteristics were achieved. The short-term wins also helped to demonstrate the value of our early efforts, gave us the opportunity to celebrate early successes, and brought additional players into the fold.
Consolidate gains and produce more change
Kotter states that the declaration of “early victory” and resistance to change can undermine early success.8 It is therefore critical to consolidate gains and, often, to produce more change. New projects, themes and change agents can reinvigorate the process. In our setting, the consolidation of gains occurred in a number of ways. After the first faculty development workshop on teaching professionalism, a debriefing session took place that involved the workshop planners, the associate deans, and the small-group facilitators. In addition to discussing the workshop process, a consensus emerged that further faculty action was required to ensure that students understood professionalism and behaved according to its precepts. Thus, a report to this effect was sent to the dean and the associate dean responsible for undergraduate education, emphasizing the need to teach the principle that the physician fulfills two roles: that of healer and professional. This report, which used the word physicianship—a term already used by Cassell51 and Papadakis and colleagues52 to refer to these dual roles—recommended that a distinct program on physicianship be established, based on separate, but complementary, approaches to the healer and the professional. It also included numerous detailed suggestions for teaching strategies across all four years of the curriculum.
This report was reviewed by the curriculum committee, which is chaired by the associate dean responsible for undergraduate education. This committee chose to establish three working groups consisting largely (but not entirely) of individuals who had been involved in the faculty development program on professionalism. The mandate of the first was to recommend a curriculum on teaching professionalism. The second working group focused on the teaching of the healer role. The third was established to look at new ways of evaluating the physician as healer and professional, as it was recognized that a system of evaluating students had to be linked to the teaching of physicianship.
The recommendations of these working groups, some of which evolved directly from the faculty development workshops, and all of which enjoyed the strong support of the dean, formed the basis of subsequent faculty development activities aimed at supporting and informing curricular change. Briefly, these recommendations suggested that we should:
▪ establish a longitudinal four-year program on physicianship that would include specific activities devoted to teaching the roles of the healer and the professional;
▪ create new learning experiences and regroup existing successful activities under the umbrella of physicianship; and
▪ revise McGill’s evaluation system.53
These recommendations also stressed that the cognitive base of physicianship be taught explicitly and that opportunities for reflection on physicianship be provided throughout the curriculum. The importance of communication skills to the dual roles of healer and professional was also recognized, and a faculty-wide workshop on teaching communication skills was organized in February 2004. The goal of this workshop, which welcomed 80 faculty members, was to introduce and explore different models of teaching communication skills, and after the workshop, a newly established committee recommended that we implement the Calgary–Cambridge model,54,55 a successful model of teaching communication skills, at McGill. Finally, the recommendations of the three working groups, as well as the committee on teaching communication skills, were discussed by a special task force mandated to make specific, detailed recommendations for curricular renewal. The task force report56 was approved by the curriculum committee, the dean, and the faculty executive; it was also endorsed by the entire faculty leadership, including departmental chairs, at a retreat specifically devoted to curricular change.
Anchor new approaches in the culture
According to Kotter,7 the final step in transforming an organization is to institutionalize the new approaches in the culture of the institution. This refers to articulating the connections between new behaviors and cultural norms and developing the means to ensure leadership development and succession. New approaches are being anchored in the culture of the Faculty of Medicine at McGill University by implementing a major revision to the undergraduate curriculum based, in part, on the different suggestions made during the faculty development workshops. Moreover, endorsement of curricular renewal at the Faculty of Medicine retreat led to the following recommendations, all of which have now been implemented.
▪ The overall organization of the scientific and clinical aspects of the systems-based curriculum should remain unchanged.
▪ A longitudinal four-year course, addressing the role of the healer and the professional, should be established under the umbrella of physicianship.
▪ There should be separate activities devoted to teaching the roles of the physician as healer and professional.
▪ There should be class-wide “flagship activities” devoted to physicianship on a regular basis throughout the four years of instruction; these would include the body donor service and the white coat ceremony.
▪ Existing and successful learning experiences should be regrouped under a series of courses on physicianship; this would include the teaching of ethics, spirituality, and palliative care medicine.
▪ Emphasis should be placed on providing a cognitive basis for the role of the healer and the professional and creating regular, stage-appropriate opportunities for experiential learning and reflection on the two roles throughout the four years of undergraduate education.
▪ A mentorship program, using respected role models, should be established. The mentors, called Osler Fellows, would work with six medical students, who would remain with them for four years. A separate series of faculty development workshops, specifically designed for the Osler Fellows, would help to build a sense of community, ensure understanding of the objectives and methods of the proposed program, and foster the acquisition of new skills such as narrative medicine57 and reflective practice.38
▪ The mentors should supervise the creation of a physicianship portfolio for each student. The portfolio,58 which would include material relevant to the roles of the healer and the professional, should be paper based, designed to promote self-reflection, and not used for summative evaluation.
▪ Each student should be required to pass the physicianship course before proceeding to the next year.
▪ It would be important to establish a revised system of evaluating professional behaviors. A pilot study of a new method, the Professionalism Mini-Evaluation Exercise (P-MEX),59 a modification of the mini-CEX60 that grew directly out of the workshop called Evaluating the Physician as Healer and Professional, has been completed. A revised global assessment form, using the behaviors identified in the workshop, has been designed and is now being used in the undergraduate program. We are also considering the implementation of a system for student evaluation of faculty professionalism.
▪ The associate dean responsible for undergraduate medical education should complete his term and become the director of the office of curriculum development. Several faculty members would be chosen to serve as directors of different aspects of the new physicianship program.
▪ A review of many of the elements of the clinical method (e.g., the template for the written case report; the physical examination) should be undertaken by the Faculty of Medicine.
▪ A revised and expanded course on communication skills should be instituted, based on the Calgary–Cambridge guides to the medical interview.54,55
▪ External consultants, including Drs. Eric Cassell and Rita Charon, should assist in the implementation of the new curriculum and the evaluation of its impact.
As this article is being published, the third year of the new curriculum is under way, with the third group of Osler Fellows in place.
The change to McGill’s curriculum occurred because of the realization that there was a need for change, ongoing support from the leadership of the faculty, the presence of local experts and champions for professionalism and healing, and the implementation of a strong faculty development program. The vision for curricular change at McGill grew slowly from the moment when it was appreciated that professionalism required more than one lecture or designated teaching activity. Moreover, it was recognized early that both the informal and hidden curricula required attention and that the faculty had to be fully engaged for meaningful change to occur.
As we have outlined in this article, faculty development has been implicated at every step, from the initial workshops, which communicated the nature of professionalism to the faculty, to the sessions exploring methods of teaching and evaluation, the roles of the healer and the professional, and the concept of physicianship. More recently, faculty development has been involved in training the Osler Fellows, focusing on their roles as mentors and small-group facilitators, and introducing them to the concept of portfolios, reflective practice, and narrative medicine. At the same time, we are quite aware that we still have many faculty members who are, as yet, uninformed about professionalism and how to teach it, and we need to develop new activities to reach them as well. However, the momentum that has been built during the past decade is likely to continue, particularly as the overall vision enjoys broad faculty support.*
Clearly, a number of factors, including strong support from the dean and other educational leaders, have played a critical role in this change initiative. It must also be stressed that the curriculum has evolved during the past 10 years, and many of the flagship activities had been in place for several years and were functioning well. It is also too early to assess the results of our curriculum, which is still a “work in progress.” Although the educational blueprint is in place, additional activities need to be planned and implemented, and, as is true with any curriculum, there will undoubtedly be unforeseen events requiring adjustments. In the short term, we need to introduce activities into each major academic unit of the curriculum to allow for experiential learning of the roles of healer and professional. Also, the importance of residents in the learning experience of medical students has led us to recognize that further education of residents as role models is required. The identification of behaviors indicative of professional values and the development of the P-MEX has allowed us to begin to address the issue of evaluation, but we, along with most of the profession, must still do better, and we must begin to evaluate the professionalism of our faculty members.
However, several things can be said with confidence. More than 300 faculty members have voluntarily spent at least a half-day at faculty development workshops focusing on the teaching and evaluation of professionalism; we now have a cadre of clinical teachers, small-group leaders, and mentors, all of whom have enabled us to expand the teaching of professionalism in an incremental fashion throughout the faculty; and our faculty development program has had an impact on both the informal and the hidden curriculum, as students, residents, and faculty are aware of the nature of professionalism and the importance of professional behavior. Faculty development has clearly been a powerful instrument of change in our setting, and we hope that other programs can benefit from some of our lessons learned.
1 Sullivan W. Work and Integrity: The Crisis and Promise of Professionalism in America. 2nd ed. San Francisco, Calif: Jossey-Bass; 2005.
2 Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982.
3 Hafferty FW, McKinlay JB. The Changing Medical Profession: An International Perspective. New York, NY: Oxford University Press; 1993.
4 Freidson E. Professionalism, the Third Logic: On the Practice of Knowledge. Chicago, Ill: University of Chicago Press; 2001.
5 Kirch DG, Grigsby RK, Zolko WW, et al. Reinventing the academic health center. Acad Med. 2005;80:980–989.
6 Suchman AL, Williamson PR, Litzelman DK, et al. Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school. J Gen Intern Med. 2004;19:501–504.
7 Kotter JP. Leading change: why transformation efforts fail. Harvard Bus Rev. 1995;73:59–67.
8 Kotter JP. Leading Change. Boston, Mass: Harvard Business School Press; 1996.
9 Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–871.
10 Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73:403–407.
11 Centra JA. Types of faculty development programs. J Higher Educ. 1978;49:151–162.
12 Bland CJ, Schmitz CC, Stritter FT, Henry RC, Aluise JJ. Successful Faculty in Academic Medicine: Essential Skills and How to Acquire Them. New York, NY: Springer-Verlag; 1990.
13 Steinert Y. Faculty development in the new millennium: key challenges and future directions. Med Teach. 2000;22:44–50.
14 Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med. 1998;73:387–396.
15 Dunning AJ. Status of the doctor—present and future. Lancet. 1999; 354(suppl):SIV18.
16 Krause E. Death of the Guilds: Professions, States and the Advance of Capitalism, 1930 to the Present. New Haven, Conn: Yale University Press; 1996.
17 Irvine D. The performance of doctors: the new professionalism. Lancet. 1999;353: 1174–1177.
18 Wolinsky FD. The professional dominance, deprofessionalization, proletarianization perspective. In: Hafferty FW, McKinlay JB, eds. The Changing Medical Profession: An International Perspective. New York, NY: Oxford University Press; 1993:11–25.
19 Cruess RL, Cruess SR. Teaching medicine as a profession in the service of healing. Acad Med. 1997;72:941–952.
20 Swick HM. Toward a normative definition of professionalism. Acad Med. 2000;75: 612–616.
21 Barondess JA. Medicine and professionalism. Arch Intern Med. 2003;163:145–149.
22 ABIM Foundation. American Board of Internal Medicine; ACP–ASIM Foundation. American College of Physicians–American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243–246.
23 Epstein RM. Mindful practice. JAMA. 1999;282:833–839.
24 Ludmerer KM. Instilling professionalism in medical education. JAMA. 1999;282:881–882.
25 Rudy DW, Elam CL, Griffith CH. Developing a stage-appropriate professionalism curriculum. Acad Med. 2001;76:503.
26 Arnold L. Assessing professional behaviors: yesterday, today, and tomorrow. Acad Med. 2002:77;502–515.
27 Epstein RM. Assessment in medical education. N Engl J Med. 2007;356:387–396.
28 Wear D, Bickel J. Educating for Professionalism: Creating a Culture of Humanism in Medical Education. Iowa City, Iowa: University of Iowa Press; 2000.
29 Coulehan J. Today’s professionalism: engaging the mind but not the heart. Acad Med. 2005;80:892–898.
30 Huddle TS. Teaching professionalism: is medical morality a competency? Acad Med. 2005;80:885–891.
31 Stern DT, ed. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006.
32 Cruess SR, Cruess RL. Professionalism must be taught. BMJ. 1997;315:1674–1677.
33 Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending-physician role models. N Engl J Med. 1998;339:1986–1993.
34 Wright SM, Carrese JA. Which values do attending physicians try to pass on to house officers? Med Educ. 2001;35:941–945.
35 Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003.
36 Cruess RL, Cruess SR. Teaching professionalism: general principles. Med Teach. 2006;28: 205–208.
37 Hilton SR, Slotnick HB. Proto-professionalism: how professionalisation occurs across the continuum of medical education. Med Educ. 2005;39:58–65.
38 Schön DA. Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions. San Francisco, Calif: Jossey-Bass; 1987.
39 Ihara CK. Collegiality as a professional virtue. In: Flores A, ed. Professional Ideals. Belmont, Calif: Wadsworth; 1988:56–65.
40 Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med. 1994;69:670–679.
41 Mount B. Existential suffering and the determinants of healing. Eur J Palliat Care. 2003;10(2 suppl):40–42.
42 Mount B, Kearney M. Healing and palliative care: charting our way forward. Palliat Med. 2003;17:657–658.
43 Kearney M. A Place of Healing: Working with Suffering in Living and Dying. Oxford, UK: Oxford University Press; 2000.
44 Steinert Y, Cruess SR, Cruess RL, Snell L. Faculty development for teaching and evaluating professionalism: from programme design to curricular change. Med Educ. 2005;39:127–136.
45 Royal College of Physicians and Surgeons of Canada. CanMEDS 2000 Project. Skills for the new millennium: report of the societal needs working group. Available at: (http://rcpsc.medical.org/canmeds/canmed_e.html
). Accessed September 7, 2007.
46 American Board of Medical Specialties. Annual Report and Revised Reference Handbook. Evanston, Ill: American Board of Medical Specialties; 2005.
47 Accreditation Council for Graduate Medical Education. Outcome Project. Available at: (http://www.acgme.org/outcome
). Accessed July 26, 2007.
48 Association of American Medical Colleges. Professionalism in Contemporary Medical Education: An Invitational Colloquium. Washington, DC: Association of American Medical Colleges; 1998.
50 Norcini JJ, Blank LL, Arnold GK, Kimball HR. The mini-CEX (clinical evaluation exercise): a preliminary investigation. Ann Intern Med. 1995;123:795–799.
51 Cassell E. The Nature of Suffering and the Goals of Medicine. New York, NY: Oxford University Press; 1991.
52 Papadakis MA, Osborn EH, Cooke M, Healy K; University of California, San Francisco School of Medicine Clinical Clerkships Operation Committee. A strategy for the detection and evaluation of unprofessional behavior in medical students. Acad Med. 1999;74:980–990.
53 Cruess RL. Teaching professionalism: theory, principles and practices. Clin Orthop Relat Res. 2006;449:177–185.
54 Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method teaching: enhancing the Calgary–Cambridge guides. Acad Med. 2003;78: 802–809.
55 Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Oxford, UK: Radcliffe Publishing; 2005.
57 Charon R. Narrative medicine: a model for empathy, reflection, professionalism and trust. JAMA. 2001;286:1897–1902.
58 Friedman Ben David M, Davis MH, Harden RM, Howie PW, Ker J, Pippard MJ. Portfolios as a method of student assessment. Med Teach. 2001;23:535–551.
59 Cruess R, McIlroy JH, Cruess S, Ginsburg S, Steinert Y. The professionalism mini-evaluation exercise: a preliminary investigation. Acad Med. 2006;81:S74–S78.
60 Cruess SR, Johnston S, Cruess RL. “Profession”: a working definition for medical educators. Teach Learn Med. 2004;16:74–76.
Reference only in List 1.
61 Oxford English Dictionary. 2nd ed. Oxford, UK: Clarendon Press; 1989.
*Although it is beyond the scope of this article to describe the overall structure and funding of the faculty development program at McGill, it should be noted that funds for this faculty development initiative came out of the program’s base budget; no special funds were sought. Cited Here...© 2007 Association of American Medical Colleges