McGill University Faculty of Medicine

1. McGill University Faculty of Medicine Curriculum renewal Findings and implications of qualitative research with students and teachersSeptember 20, 2004 1

2. Our discussion today • Introduction and background • Goals for this initiative • Approach and methodology • Participants • What we learned • Students • Faculty • Implications

3. The goals of this work were to… • Introduction and background • Goals • Methodology • ParticipantsWhat we learned • Implications • Establish ‘where we are’ prior to initiating any change • Develop a rich understanding of educator and student perspectives • Understand the implications on changes to the curriculum • Provide the Faculty of Medicine with context so change can be tailored to the specific situation and requirements • Benchmark attitudes and perceptions of constituents • Develop ‘straw man’ recommendations on metrics to measure impact of curricular change (NA today)

4. Who we talked with… • Introduction and background • Goals • Methodology • ParticipantsWhat we learned • Implications • Student participants with a range of • Career aspirations • Points in education • Ages—including undergraduate and graduate students • Gender • Participation in joint programs (e.g. MD and PhD) • Faculty and educator participants across range of • Medical disciplines and responsibilities • Age • Gender • Seniority • Participation in curriculum change 10 years ago

5. We use a highly structured interview methodology • Introduction and background • Goals • Methodology • ParticipantsWhat we learned • Implications • Students: 1½ hour mini-group discussions • Faculty and educators: 1+ hour one-on-one interviews • Interview process probes for • Facts and perceptions • Thoughts and feelings • Topics included • Original motivation to become a doctor • Importance of role models • Strengths and weaknesses of today’s curriculum • ‘McGill-ness’ • New curriculum—and concerns about how to implement and measure • All participants responded to 2 ‘concept statements’ on the proposed changes to the curriculum

6. We interviewed 21 students in 6 mini-groups • Introduction and background • Goals • Methodology • Participants What we learned • Implications Men -14 Gender Women - 7 Mean: 25.8 Age range 20 - 43 Distribution by class Med 1………7 Med 3………4 Med 2………3 Med 4………7 Interviews - 21 Citizenship Canadian - 17 USA - 4 Cohorts* MDCM (MedP): 7 Ddl. program: 2 MDCM (4 yrs): 12 *MDCM (Med P): Comm. College; no degree on admission; MDCM (4) have university degree; Dbl.: admitted with degree to MD/MBA or MD/PhD

7. A summary of what we learned from students • Introduction and backgroundWhat we learned • Students • Educators • Implications • They are idealistic at the outset, with deep respect for McGill • There are significant issues with the current curriculum • The intensity of the didactic learning is very stressful • The quality of the clinical education is dependent on the ‘luck of the draw’ and the clinical teachers they get • These two aspects are inadequately integrated and synthesized • As their education progresses, students become increasingly cynical • They see themselves grow less idealistic and patient-focused • Virtually all are enthusiastic about changes to the curriculum • 1st year students assume the curriculum is this way • Many worry that physicianship can be taught, and say it requires teachers who can mentor

8. For the greatest part, all students are motivated to become doctors to do ‘something for people’ • Introduction and backgroundWhat we learned • Students • Educators • Implications • Students’ motivation for becoming doctors come from • Strong role models • Powerful life experiences • Internal drive to ‘make a difference’ • Intellectual stimulation and challenge are important aspect of this career • But the change in student perspective from 1st year students to graduating seniors is palpable • The practicalities of the medical education changes perceptions and expectations

9. First year students (just starting) are highly idealistic about • Introduction and backgroundWhat we learned • Students • Educators • Implications • Their motivations and goals • “Personally, there’s a sense of duty…I will not necessarily take pleasure in helping others…but it’s something I have to do.” • “I want to stay a good person; McGill’s very good on that… you have to make decisions and make a good decision…be a good person, be a doctor when you need to be.” • A good doctor is… • “…[one who] maintained their humanity, being a medical machine would be good…the biggest thing is maintaining the human part and accompanying the patient through the healing process. You have to be a good person to your patient.” • “…give them your full devotion. Not like a strict father, but get the patient into the decision process…understand where the patient is coming from…you need to understand the person.” • Their upcoming education • “Medicine is an apprenticeship. You learn from watching people interact…it would correspond to the ideal level of what medicine should be…this is the way it should be.”

10. But even first year students have begun to worry… • Introduction and backgroundWhat we learned • Students • Educators • Implications • About the effect of their education on their values • “I’m getting very worried that the people-oriented part is going down the drain…the scientific knowledge and learn to communicate it appropriately; this probably can be integrated properly…I’m sure it’s not polar opposites…there’s got to be a way.” • “Be aware of what you like and don’t like about people who teach you…I have teachers who I know I don’t want to be like.”

11. By the second year, students are wrestling with the difference between their expectations and the reality • Introduction and backgroundWhat we learned • Students • Educators • Implications • Of the curriculum today • “I thought medical school would prepare me to think so that by the time I got into the hospital I was prepared for real life…it would be better if I had been given the tools of how to bring them all together. Now, if you ask me how much I remember from that first year and a half, it’s not as much as I thought. Lots of unimportant issues…focus on memorizing small details.” • Of ITP • “…it suffered from one large issue. It wasn’t able to compete against the hard core didactic courses which had exams…it wasn’t as effective in getting those elements into place.” • And warding off cynicism • “I know how I am now, but I wonder if I can lose it by focusing on what I have to focus on…maybe I don’t have to worry that what I have won’t be shoved aside. Maybe you can’t teach empathy, but if you can preserve it and reminded it’s important…”

12. By the third year, students are in focus • Introduction and backgroundWhat we learned • Students • Educators • Implications • Motivation is sharpened • “I like being challenged mentally. I like interacting with people. I like to feel I’m contributing. …I’ve had wonderful experiences with patients…very moving… couldn’t get that outside this profession.” • “I would like my contribution to be in preventive healthcare. The two biggest killers are obesity and smoking, so I would like to do research in those things.” • As are their perspectives on their education • “In our first 1.5 years, I expected more integration, not isolated problems—especially in physiology…in the clinical part, you have to look at the whole picture. We did some of that but not that much. Some doctors are excellent, some are terrible. You should learn the anatomy and physiology because it’ll carry you through your entire career. The approach was too theoretical.” • “…by the 2nd half of the 2nd year, you’ve done the classroom learning, but go into the hospital and get things done…the teaching was very poor. A topic here, and a topic there…because it was the hospital, the doctor didn’t show up…there was a lot of waiting around…the physical exam…is all learned in a bubble. You remember part of it, but you don’t know it properly.”

13. Fourth year students • Introduction and backgroundWhat we learned • Students • Educators • Implications • Are articulate about their disappointments • “There’s a lot of cultural things about being a doctor that I wasn’t prepared for—things that take you away from the patient. …Some teachers were very good after examining a patient. They talked to you and put it in context. Some teachers try to address these issues as you go along. But with most teachers, you just go from a lecture to the ward.” • “The times I’m most cynical is when I’m not thinking about the patient. I am thinking just medical and the patient is forgotten.”

14. …and by fourth year, students • Introduction and backgroundWhat we learned • Students • Educators • Implications • Appear to articulate their motivations in different terms • “For me an ideal doctor is a human broker. Broker between one entity—the patient who is complex and you are taking information, and the other entity is medicine, then apply it to the patient. Then, have to take themselves into account. Then come to the solution that takes into account all three.” • ..and their changed perspectives • “I thought I’d be taught more, get more hands-on teaching at the hospital, more mentorship, more inspiration. I thought I’d see why I chose this career. That didn’t happen enough. I was trained well, but not taught well. I had the idea that I’d be inspired more by mentors.” • “I’ve lost some illusions about medicine. I can see how someone can get through medical school and not be a good doctor, not care about patients, just care about money. Now I have priorities. Medicine is so demanding and I know that I can’t do everything.” • “Certain environments took a huge toll on me…at a teaching hospital, they didn’t care about teaching. They would want to get home 15 minutes earlier…you don’t go over it and no one really teaches it to you. So you don’t really get as much out of it as you should.”

15. Fourth year students • Introduction and backgroundWhat we learned • Students • Educators • Implications • Describe the effects of the structure of the system and their education • “Students are treated as if they don’t have rights. It’s very hierarchical.” • “There’s so much conflict set up and you’re afraid to report it…There are conflicts of interest. Psychological support is needed…someone who is familiar with medical students and will keep complete confidentiality: independent and at arms length. We don’t tend to seek out help; I don’t even have a family doctor and I’m going to become one.”

16. Graduating seniors… • Introduction and backgroundWhat we learned • Students • Educators • Implications • Talk about the importance of role models and mentoring • “It comes down to whether a patient has been helped, gone the extra mile, or I know how to do something to help someone in the future. Whenever I’ve felt empowered enough, or someone has sat me down and taken the time to not assume I know how to do something perfectly…when someone has been realistic and said ‘let’s go over this again’. • And have reframed their motivations • “Selfish reasons. I feel good when I can make an impact on people’s lives and I think this is how I can make the biggest impact.” • “I want to do something useful and like to work with people.”

17. Reasons for going to McGill • Introduction and backgroundWhat we learned • Students • Educators • Implications • For new students • “I chose McGill because of Montreal, a city I’d like to live in while I’m studying medicine. And it’s pass fail…non-competitive.” • “I’d like to come out super competent. McGill offered that.” • “I have a friend that’s not on a pass fail system. I’m so happy that we are. We work as a team. • “I like being thrown into harder situations…there’s a lot of challenge here.” • Matured perceptions • “The groups are too big…I’ve been disappointed with this. I thought McGill would have great problem-based learning…” • “The McGill name can open doors. I don’t know if any medical school can meet your expectations.” • “The principles we were taught were well taught, but once you get in the hospital and real life is starting, you tend to forget the principles because you work with doctors who don’t apply them.”

18. The curriculum today • Introduction and backgroundWhat we learned • Students • Educators • Implications • Appears over-weighted on certain dimensions… • “For a year and a half, didactic was the focus. Once we get into the hospital we realize that all that didactic stuff is not the focus, but using the right words and being empathetic are.” • “I won’t remember most of what they teach me and there will always be a book for that. There’s no synthesis, no big picture. Just memorization of minutia.” • “They get the expert to lecture. But he can’t lecture. This university does not always discriminate.”

19. The curriculum today • Introduction and backgroundWhat we learned • Students • Educators • Implications • But lacking on other dimensions • “What is lacking is the integration of the knowledge and time for reflection…few teachers want to integrate anything. Better to have practitioners do the teaching.” • “Modeling behavior is important. It’s hard to put that into a package and teach it. It’s hard to get staff members willing to teach. It depends on how an individual’s staff member or tutor is as a teacher.” • “They’re trying but they’re not very organized and they can’t see it very well because they’re not doing it everyday. Need better communication between students and administration. Communication is terrible. Admin is not very active in putting themselves in our shoes.”

20. The description of the changes to the curriculum is greeted with • Introduction and backgroundWhat we learned • Students • Educators • Implications • Disbelief on the part of first year students who expect that ‘healing’ and ‘physicianship’ are already there • “They’re going to keep the technology and add this.” • “…there’s no way that’s not embedded already…the whole healing thing…I’d expect that to be there already.” • “I’m sure these things are going to come about…being around the medical community. You’re bound to pick these things up…aren’t these things there already?” • Tentativeness on the second year students • “I like that it will be more integrated. We start empathetic, but by the time we’re done, it’s been beaten out of us. I don’t want this to happen to me. This is ideal.” • Worry about time… • “You don’t need someone to teach you empathy, you need the time to be empathetic. You have to survive in the system as it is set up now. It’s more of an opening to help people like us who already have these qualities not to lose them.”

21. Among students further along in their education, these changes seem like • Introduction and backgroundWhat we learned • Students • Educators • Implications • A return to traditional values • “It’s not new, it’s old. Maybe we just got away from it. It’s like a pendulum. Had healing, then science came up quickly and overshadowed the other aspects. It’s almost a renaissance.” • …tempered by the practicalities • “I think I know what they mean…it surprises me we have to talk about…that you have to teach…to be respectful of the patient. I don’t know if you can teach it. If it’s not in your upbringing, I don’t know if you can teach it.” • “Really the way to deliver on these goals is through role models, through examples, the way good doctors are, the way good interpersonal skills interact. You see it on the faces of patients. You feel it in the room when there are good communications.”

22. And although these changes sound beneficial… • Introduction and backgroundWhat we learned • Students • Educators • Implications • Can they be taught? And how? • “If we could learn it, it would be very valuable. If it is teachable, absolutely valuable to me. Must be taught in small group format. Discussion groups more valuable in 3rd and 4th year because that’s where we’re exposed to situations. We’re so busy we don’t have time to reflect on that.” • “People think they know how to listen, but I was taught step-by-step how to listen and it was revolutionary to me because I realized I was a terrible listener.”

23. Many are concerned about teaching language and… • Introduction and backgroundWhat we learned • Students • Educators • Implications • Communication and other professional skills • “How do you standardize communication? I’m concerned if some of these things are graded because people will just mimic the ways to communicate.” • “‘Teach language and communication skills explicitly’ How will it be put into practice? Evaluated?” • “Observation skills would be interesting.”

24. And fundamental changes to the curriculum • Introduction and backgroundWhat we learned • Students • Educators • Implications • Clinical method and ‘physicianship’ • “Lots of words, good intentions. I thought this is what the clinical method is focused on. They’re going to focus it more. It’s nice to teach this, but when you get to real life, it’s hard.” • “Maybe I’m cynical, but the ability of someone to practice physicianship depends on the person’s values. But good intentions are there.”

25. How to measure • Introduction and backgroundWhat we learned • Students • Educators • Implications • The success of the curriculum change • “I don’t understand the modification of the exams.” • “If my evaluators and my teachers are taking it seriously, then I am. Now, I get that it’s not a priority. In that sense, it’s good.” • “Big disconnect between lecture and how you’re evaluated. 5% of evaluation is on professionalism. Science and technology is the bulk of what makes you a good student because of how the evaluations are structured.” • “The way the first year and a half is, it’s either pass or fail. I don’t think they’ll fail someone on poor communication. They let it slide…everyone would pass this unless they were grossly inappropriate.”

26. Worries… • Introduction and backgroundWhat we learned • Students • Educators • Implications • About the reality of the world… • “But can we change the reality of the medical system? If we can have the new cadre of doctors, but can still only spend 7 minutes with the patients… • “How do you retrain the doctors that are training you?”

27. Would these changes be good for the McGill education and McGill’s reputation? • Introduction and backgroundWhat we learned • Students • Educators • Implications • Yes—but it will require focus and commitment • “I don’t think this will be a lecture, but a change in how everything else will be taught.” • “I think that if each of these goals can be obtained, McGill would be great. The faculty really needs to buy into it.” • “It is needed. The real benefit is that it is a skill that gives back. As soon as your students adopt it and become residents and physicians, they will teach it.”

28. We talked with 11 faculty and educators in one-on-one interviews • Introduction and background • Goals • Methodology • Participants What we learned • Implications Men - 6 Gender Women - 5 Family Medicine Pediatrics Departments Medicine (3) Physiology Neurology Psychiatry Interviews - 11 Ophthalmology Surgery Pathology Years in practice: average 25 Range: 5 - 43 Rank Professor: 4 Asst. Prof.: 4 Assoc. Prof.: 2 Lecturer: 1

29. A summary of what we learned from educators • Introduction and backgroundWhat we learned • Students • Educators • Implications • Their deep connection to basic values is highly congruous with students’ values—although they are unaware of it • Their concerns are informed by experience and knowledge of the ‘system’ today • The concepts in the curriculum changes are extremely attractive • They herald a return to the values that drove their original participation in this field • They believe deeply in the need for the balance of science and human skills • The word ‘healing’ is charged—negatively and positively • Many are concerned that science has gotten out of hand, they worry about implementation of the ‘softer’ skills • Virtually all believe these changes, after successful implementation, will create added distinction for the McGill education itself…and how the institution is perceived in the world

30. The motivations and goals of students and educators are highly congruous • Introduction and backgroundWhat we learned • Students • Educators • Implications • Doctors recall original goals coming from • Strong role models—often a parent or relative • Life experiences and embedded expectations • Internal drive to ‘make a difference’ • Intellectual stimulation and challenge, similarly, drive choice of this career • “It’s a nice blend of humanities and science…a prestigious thing to do although years ago I wouldn’t admit to that. There is job security. You can help humanity and it satisfies an interest in science. I have no regrets.” • Very similar descriptions of what it means to be a good doctor • “…strong and very soft. Strong and humane; have a good sense of humor…and a good sense of yourself. You need to recognize your mistakes.”

31. The curriculum today… • Introduction and backgroundWhat we learned • Students • Educators • Implications • Although impressive, and improved 10 years ago… • “Has tremendous breadth and depth. Not every basic science and clinician is good, but basically it has great breadth and depth. We have a tremendous patient population…there is a huge opportunity to work in communication. We have a lot of patient exposure and we are grounded in the patient.” • Is less than ideal • “The role model of kindness and professionalism is compromised. Students don’t understand the work environment; they become stressed, cynical, more defensive. It starts to become about their contractual obligations.” • “There’s not enough emphasis on that [physicianship]. I suspect there is a bias to science. To go deeper, there’s too much emphasis on science and technology.”

32. Frustrations with today’s curriculum • Introduction and backgroundWhat we learned • Students • Educators • Implications • Include pressure from workloads • “Clinical teachers are very stressed with clinical workloads; we are not well reimbursed. But they feel the responsibility and pleasures of teaching. But the stresses show [to students]…the beeper going off; the need to cancel clinics and reschedule. It’s astonishing and miraculous that good teaching is going on.” • Being unprepared for the role • “We’ve never been taught to teach. 90% have never been taught how to teach. Yvonne Steinert has a program to teach them to teach. Lecturers are often not interested in teaching outside their expertise.”

33. Some educators worry about… • Introduction and backgroundWhat we learned • Students • Educators • Implications • The motivations of the students • “Why do they become doctors today? It’s a well-paying career. Some of them have idealism. But the majority because it’s a good career. Prestige and money.” • “I hope they don’t do it for money. They want to help people and it’s challenging. You always continue to learn.”

34. Educators articulate concerns about deep structural issues such as • Introduction and backgroundWhat we learned • Students • Educators • Implications • The ever-present ‘chronic’ issue of how they are compensated • “Mentors are not paid, receive no recognition. You receive no praise for teaching, just for publishing papers.” • “You get paid for seeing patients; 100% of the money for clinicians is from seeing patients. If you see 15 patients in the clinic…if you have students you see 5 patients or it is not good for anyone. That has to be compensated.” • Conditions in the hospitals • “…we are coming to a horrible problem. The patients in the hospital, their average age is 80. Majority are demented, have strokes, are incontinent. They are in the saddest condition. There is no elective admittance anymore, just emergency cases. This has to be dealt with; this is what these kids (new students) will see.”

35. All are deeply proud of McGill… • Introduction and backgroundWhat we learned • Students • Educators • Implications • And its reputation… • “It’s a huge source of pride. The Harvard of Canada.” • “It’s really the most powerful English institution in Quebec. It’s very desirable…over 40% are French Canadian and it attracts international students, huge numbers of them. It gives Quebec and international flavor.” • In spite of the ‘realities’ • “This is one of the great medical schools. Of course realities are always disappointing, but the possibilities are huge.”

36. Most say the changes suggested for the curriculum… • Introduction and backgroundWhat we learned • Students • Educators • Implications • Are compelling • “No one will argue with this.” • “McGill has recognized the erosion of the relationship between physician and patient and the physician and society and wants to reexamine and reemphasize those aspects of the relationship that have weakened. The primacy of what it means to be a physician as opposed to a technician.” • And demanding • “It means a lot more mentoring. In medical education of the past, you were an apprentice. That’s gone.” • “This is a bold way of looking at things. It’s scary…which is not to say that it shouldn’t be done. It’s like Jesus and the lamb. If we change one student, maybe it’s not cost effective…but if we change 10%...the effort is worth it anyway.”

37. Many articulate their concern that ‘physicianship’ cannot be taught… • Introduction and backgroundWhat we learned • Students • Educators • Implications • That it is innate • “…it’s very difficult stuff to teach. You learn by watching. We’re not going to sit in class and talk about empathy. Part of it is the protoplasm you start with.”

38. As they reflect on the practicalities of implementation… • Introduction and backgroundWhat we learned • Students • Educators • Implications • Some are concerned about the continued focus on science • “Although it states it won’t be at the expense of science, I think it will…This is great as long as it doesn’t cut down on the science. They don’t need to know everything in the curriculum. The knowledge explosion is mind-boggling. Some is not necessary, but which part?” • “It’s like there is this strong nail with a strong elastic. The nail is that (the physicianship concept); the nail has to be reinforced. The elastic is the advancement of knowledge. We have to pull that elastic, but we cannot forget the nail.”

39. Fixing the curriculum is just one aspect of the issue • Introduction and backgroundWhat we learned • Students • Educators • Implications • Admissions, and the selection committee, are another • “…need to predict in admissions what makes for a good physician. How do you measure integrity, honesty?” • “If you have criteria, require high marks and in science, you’re selecting for a certain mindset and certain kind of people. So you get them in and try to teach them how to be compassionate…it’s the obsessive compulsives that are worried about their grades. It’s important to add this [admissions] to the discussion.”

40. Addressing the current demands… • Introduction and backgroundWhat we learned • Students • Educators • Implications • On the physician’s time is another major issue • “How in God’s name do you get there? Much is taught by example…by modeling. People who model this behavior—there are many, but they are a minority—they are burning out. If you take away half of their workload and let them do it…maybe then, but within the structure as it is, it’s impractical.”

41. To some, assessment and measurement will be critical • Introduction and backgroundWhat we learned • Students • Educators • Implications • To creating focus and success • “It will depend on how McGill evaluates these qualities. Students are very focused on their exam results. One must be evaluated on this. It’s not going to be easy. How are you going to prove to someone that you failed to show empathy?” • To others, this effort seems obvious • “I’m not going to do a random test of holding my surgery patients’ hands. I’m going to hold their hands.”

42. Motivating faculty is an important practical consideration • Introduction and backgroundWhat we learned • Students • Educators • Implications • In gaining cooperation and support • “People cannot be ordered to do it. No one has a signed contract with McGill. You have to gain cooperation… collegiality…you need to motivate and encourage them.” • “If we instituted ‘best teacher’ awards to counter problems with teaching, maybe that would help. Or maybe there is some recognition…or a better working environment.”

43. Language is an important issue • Introduction and backgroundWhat we learned • Students • Educators • Implications • And creates complexity in implementation • “…the language skills, the subtlety…what is not addressed is the issue of French and English with both students and patients. In Ontario it would be completely different. Here it is an order of magnitude more complex…how are you going to help French students get the subtleties from English patients? This is a problem that is unique to McGill.” • The word “healing” elicits an emotional response • “Healing implies the whole person. I like it. You cure a disease. You heal a person.” • “I don’t know what a healer is. It’s different from a physician. I think it’s arrogant to consider yourself a healer.”

44. Critical priorities include definition of • Introduction and backgroundWhat we learned • Students • Educators • Implications • The role of mentor in the medical education • “Modeling and feedback come first. Teaching comes next.” • “I like the concept of mentoring. It requires faculty development. If the faculty behaves as a nice guy, students will too. But a lot of physicians’ bedside manner is bad and students learn that it is acceptable.” • “It’s time to break the circle. We have very good academic people…[but] we are talking about students. What about faculty? We need the whole faculty to do this. We may have 50% today.”

45. The results will be significant and rewarding • Introduction and backgroundWhat we learned • Students • Educators • Implications • For patients • “Whatever improves patient care is good for the medical school.” • And the institution at large • “If we say “these are our values”, it’s important…it penetrates the institution.” • “If we do this well, if we succeed, it will bring esteem to the medical school.” • “Medicine is an art and a science. McGill teaches the science great. We’re going to bring the art to that same level. When art gets better, science goes up, too.” • “People would say ‘McGill does this…they’re more compassionate’. Whether you could evaluate it…it could take 50 years…but if we produce 3 more Oslers in 20 years...” • “I suspect many medical schools would come here to see how we did it. We would have better applying, better people for the right reasons. It would be back to the future.”

46. McGill University Faculty of Medicine • Introduction and backgroundWhat we learned • Students • Educators • Implications • Should explore and address the full range of related issues (e.g. admissions, assessment and measurement, workload, motivation, faculty remuneration) in order to maximize the opportunities for success with the curriculum renewal initiative • Should consider revisiting both student and educator populations for their perspectives as the program progresses to ensure you are ‘moving the needle’ • Should consider adding the ‘patient perspective’ to the implementation process • To benchmark today’s situation • To bring the patient ‘into the room’ and include patient-visible aspects in planning for changes the renewed curriculum will bring • Ensure that patient-visible effects are primary

47. McGill University Faculty of MedicineCurriculum renewal 1