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Lessons From Community Conversations: “Caring About and Caring For” “Personalizing the Profession of Medicine” Locations: Charlottetown, Fredericton, Halifax, Kentville, Saint John, Sydney Preamble In February and March 2010, the medical school held a series of Community Conversations to find out what qualities people want in their physicians of the future. These conversations were a valuable opportunity to connect with our community members and hear what they think. This public input is useful for shaping our curriculum renewal and is part of our broad consultation with members of the medical school community and academic, health and government partners. Executive summary While the community conversations were broad ranging and addressed a number of issues, some strong common themes clearly emerged. The three strongest themes focused on the need for attentive communication, collaboration, and humility within the medical profession. Our future physicians should be able to listen well; share information in an understandable manner; treat their patients, family members, staff and colleagues with respect; work effectively with others; as well as accept and be able to admit when they don’t know something or have made a mistake. These themes, in addition to themes related to the role of the physician, other core values, community involvement, conflict of interest, time demands and practice considerations, are described in detail below. What are the implications of this feedback for our curriculum renewal process? Community members invited, even challenged, us to ensure that the feedback becomes an integral part of the curriculum renewal process. Potential implications may include considering the use of rich cases – ones, for example, that may start with a family concern about a diagnosis or waiting in the emergency department and following the case through from their perspective as part of introducing what the students are being asked to learn. Other implications include inviting our community members to participate in teaching our students, in person, through video, and so on. It also means that we need to consider carefully whether we are sending the same messages through our evaluation methods about what is important for students to know and learn as demonstrated in our Overarching Objectives. Further ideas and suggestions are contained at the end of this report, and we invite you to consider how community voices can shape and influence our curriculum renewal process. Note: All phrases in quotation marks come directly from our community members. 1 Overview and reflection on the community conversations process All community conversations focused on the question, “What qualities make a good doctor?” Some community members came with lists of their thoughts while others called and sent emails if they were not able to attend in person. While the numbers for each session were relatively small (with New Brunswick having the strongest attendance), the engagement was high and the positive response was clear. Those in attendance ranged in age from early twenties to early eighties and came from a broad range of backgrounds, education and training levels. Some were there primarily as parents, partners and patients; others came as persons involved in the health sector; and, others were present to provide input on behalf of their community and its needs. All involved in the conversations wanted to provide a balanced perspective on the qualities that make a good physician; no one was there to “bring physicians down”, but were instead eager to share what we can learn from both the positive and negative experiences that people have had. The sessions also provided the opportunity for community members to provide feedback on the Overarching Objectives diagram recently developed within the Faculty of Medicine (FoM). This occurred near the end of each session and offered an appropriate way to compare and contrast what had been discussed with what is happening within the FoM. Feedback was generally positive (see below for further comments). As a form of relationship-building with our Maritime communities – those whom we serve as part of the FoM – the response we received clearly indicates that people are interested in what we are doing and appreciate the chance to participate in the current changes and curriculum renewal process. In fact, the Communications Department received a number of calls from other communities asking if a session could be held in their area. Future community conversations, focused on other key questions of interest, would likely draw more community members and continue to reinforce the message that we are all partners in teaching, training, and supporting our future “good doctors”. 2 Key observations and themes All community conversations mentioned the need for physicians to be intelligent, meaning they can learn the necessary skills and knowledge as part of becoming a good physician. For most groups, it was assumed that the development of the relevant skills and knowledge (in terms of learning about the body and illness) was somewhat of a given; even though some specific suggestions were made about how to expand what is taught in these areas (detailed below). There was an expectation of competence for our future physicians, and as you will see below, this expectation includes more than a facility with the biomedical aspects of medicine. Community members focused on the core values, important attitudes for practice – the “essentials” – that are necessary for being a good doctor. While some difficult stories and examples of bad practice were shared, the emphasis was on learning from these. The community members also shared stories and examples of the “best” of the profession, using these as launching points for naming what we should emphasize and build on in the curriculum. 1) Attentive communication The need for attentive communication was one of the first and often repeated comments brought forward by community members. This involves listening to patients and hearing their concerns – in essence, attending to and trusting what patients are saying as the starting point. It also includes asking questions and not making assumptions right off the bat. Some community members talked about being dismissed or made to feel that what was important to them was not of interest, and how hurtful this was – one community member stated, “I felt like a grain of sand”. Ultimately, communicating well helps to establish and maintain the therapeutic relationship. Communication skills include being able to share information in an understandable way, not only with patients and family members, but also with colleagues and team members. 2) Collaboration and collegiality Community members noted that it is challenging to determine exactly what we mean by collaboration both in general conversation and when assessing the Overarching Objectives diagram. Collaboration was frequently mentioned as important and essential to being a good physician, but it was clear that this same word may mean different things to different people. For example, is collaboration about being part of the team, recognizing that others may take lead roles or is it about being the leader of the team in all cases? The conversations reflected the need for physicians to collaborate with: o Other physicians (e.g., second opinions) o Health care providers (e.g., nurses, social workers, pharmacists, etc.) o Other community members who contribute to health (e.g., midwives, naturopaths, massage therapists, public health nurses, etc.) o Patients and family members? (How is this framed or understood?) Discussion around this last point was significant in the sense that it wasn’t always clear to some whether being a collaborator as a physician included the patient and the “push 3 and pull” of family involvement that some persons experienced. For example, the assumption is often made that family members will be involved and provide care at home and yet there seems to be relatively little engagement with the family around this. The suggestion was that there should be ways to engage the family even while respecting patient confidentiality. Finally, some asked about the connection between collaboration and shared decision-making – how do we understand the latter? Linked with this discussion about collaboration was a discussion around the value of interprofessional education. In other words, if we expect our future physicians to be able to work well with others, are we providing them with opportunities to learn how to do this? Are we demonstrating this within the medical school? 3) Humility and integrity Community members talked about the importance of physicians acknowledging their limits, in terms of knowledge and abilities, as well as admitting when they have made mistakes. Community members recognized that physicians will sometimes make mistakes and indicated that it is how these mistakes are dealt with that can change how a patient feels about what’s happened. The phrase, “don’t let the ego get in the way” was used verbatim at three sessions. As other community members put it, this is “about not trying to be all things to all people, but figuring out what you can offer.” This also includes the ability of physicians to recognize that others in the health field may have expertise and skills that could benefit patients and facilitating connections with these persons as appropriate. Encouraging and supporting reflective practice, self-reflection and self-awareness, related to one’s role and approach as a physician was felt to be a very important component that can enhance humility and integrity. As some community members asked, “are you a person or physician first?” 4) The role of the physician In discussing collaboration and the relative scopes of practice of different health care professionals, some discussion focused around what the role of the physician is and should be. This relates in part to making the best use of a physician’s time (e.g., renewing prescriptions), but also in reflecting what the core of a physician’s skill, knowledge, and attitudes are centred on. If we can answer the question of what the role of a physician is – and as distinct from other health roles – this can facilitate ensuring the curriculum is focused on what is of most importance for being able to fulfill this role. The community conversations highlighted the difficulties with an exclusive focus on “curing” as the only measure of success for physicians and placed the emphasis more broadly on “caring”. 5) Patient/person-centred care This theme captures an additional cluster of points (and add to that above) that were discussed in relation to being a good doctor and reflect the high importance our community members place on good people skills. Many of the points overlap and are interconnected, focusing on key values: 4 Treating patients with respect – community members shared stories of being treated with disdain, being dismissed or stigmatized, and sometimes being ridiculed by their physicians. This was often connected with particular illnesses, such as mental health conditions, but was not limited to any specific context. This deeply affected the sense of self of these persons and greatly challenged their ability to trust their physicians (or even other physicians). Empathy/kindness – community members do look to their physicians for understanding; people emphasized that what is always important is making the human connection, regardless of whether the physician can cure or fix what is happening (and members noted that they know this is an unrealistic expectation that some have of physicians and that some physicians have of themselves). This was also framed by a community member as being part of “caring authentically”. Being accepting and welcoming of patients – community members emphasized the importance of feeling welcome and accepted in the context of receiving health care, especially those from different backgrounds and contexts, including those for whom English is not their first language A key example was given from the Acadien French-speaking community in Cape Breton about how important this is and the difference it can make in feeling engaged in one’s health care. Lifelong learners - many community members indicated the importance of physicians being open-minded (rather than closed) at the end of their undergraduate training. At three sessions, people conceptualized their ideal of the lifelong learner with the first diagram below and they want to avoid the closed “top of the triangle” at the end of medical school. Open-minded Close-minded versus The desire was for our medical students to leave medical school asking questions, being open to new learning, and able to think outside of the box when needed. 6) Community involvement and teaching approaches There was a clear recognition of the need for students to be exposed to a wide variety of patients and community settings/contexts of care. Many groups discussed specific groups/contexts that would be important, including: o Persons with mental health issues, including those who are living well (not just the “worst case”) o Veterans and those who have been in/exposed to war and conflict o Transgendered persons 5 o Geriatric persons/patients – knowing this is a growing aspect of care, this is an important area within which to educate our students but also a potential opportunity to break down stereotypes and ageist assumptions o Practice in rural areas, community health settings – concern was expressed about medical students in Halifax not learning about what is happening in other areas of the Maritimes; this could be addressed by ensuring students have opportunities to “get out of Metro”. It could also be encouraged by discussing the relative merits of practice in different contexts. o French community members and members of various cultural and ethnic backgrounds 7) Conflict of interest – links with pharmaceutical industry Three of the community conversations raised questions about the links between physicians and the pharmaceutical industry. Do physicians get payments for every prescription that they write? Is the pharmaceutical industry influencing physicians’ prescribing practices? Fundamentally, there was a real concern about the number of drugs that are prescribed and how quickly they sometimes seem to be prescribed (e.g., the “quick fix”). The link to the curriculum for medical students is that future physicians need to be prepared to evaluate the evidence for different drugs and for understanding other approaches that may be drug-free for some illnesses and conditions. 8) Preparing our future physicians for practice A portion of the community conversations focused on the aspects of practice that influence the sense that physicians are able to provide good care and feel good about the care they are able to provide. While some of the learning related to practice, and how one chooses to practice as a physician, clearly takes place during residency, there was a sense that some attention to this should be provided in the undergraduate curriculum to help establish a foundation for our future physicians to work from. o Time demands - Many community members noted the busyness of physicians, both as something that can detract from good patient care and as a seeming symptom of the health care system. People asked whether we are teaching or, at least beginning the discussion with our students, about the choices they make in terms of setting up practice (e.g., sole family physician, community health centre, etc.) and good time management skills. As well, in terms of being busy, this wasn’t seen to be a reasonable excuse for being rude or dismissive to patients or colleagues. Community members pointed to current physicians who operate under the same time pressures as others, but don’t seem to make it feel rushed. Connected to the discussion about respect, community members also indicated that it often felt like doctors didn’t appreciate the time demands on their patients and the problems associated with making people wait for long periods. o Changing the health system and choices about practice - Some discussion also focused on whether we are helping our medical students appreciate that they will have real power within the health care system to encourage change that is good for patients as well as their own practice. Will our future physicians be able to 6 challenge the status quo? Will they be good leaders or advocates and what are the skills needed for this? Do they appreciate how fee for service versus salaried positions may influence and shape care? Further, are we helping our future physicians appreciate that who they hire, for example, as their receptionists make a big difference to the tone and feel of one’s practice for patients? Are we doing enough within the medical school to break down the stereotypes and negative associations with some of the choices about what doctor one wants to become (e.g., surgeons don’t need to have social skills, psychiatry isn’t a valued profession, family doctors are at the bottom)? o Specialization? - Another theme emerged related to the seeming fragmentation of care by specialization and the tensions this can create. Some expressed the value in seeing a specialist, knowing that you will get the most up-to-date approaches, while others noted how in focusing on each part of the body, there seems to be no one looking at the whole patient or person. Are we helping our students to appreciate these aspects of care and/or providing a foundation from which they can critically assess what they may learn in residency? 9) Accountability A number of the community conversations raised the issue of accountability, especially with respect to wondering to whom physicians are accountable? Are physicians accountable to patients? What mechanisms are available for ensuring accountability? While this may extend somewhat beyond the curriculum renewal process, it does raise the larger issue of helping our students and community better understand what accountability means and that it should be part of good practice. 10) Feedback on the Overarching Objectives diagram Overall, there was a sense that the diagram represents the ideal – which is great if we can do it! Many noted that this is a “tall order” for any physician to achieve, while still being an important statement about what is important and should be strived for. The diagram was felt to reflect much of what was discussed. Community members appreciated that it is meant to be patient-centred and this is a valued (re-)focusing of the profession - even though there was some discussion about the appropriateness of the use of patient versus person and the choice of language in this regard. Some questions and comments about the words and focus of the diagram included: o Role of family (however is defined by patient); where is this on the diagram? o While it is true that physicians are focused on each patient, does this model reflect enough the physician’s role within the health system and all the patients they have responsibility for? o Is the health focus strong enough (as opposed to a medical model)? o How are the human sciences described? o Is community contributor the right way to capture this expectation? For example, some members saw contributor as someone still standing apart rather than being involved and engaged with the community 7 o Importance of advocacy for patient and for health (in terms of changes to the health system) o Should self-care be part of the diagram? o The word “reflective” seems more passive than self-reflection or self-awareness 11) Admissions If this is what the FoM hopes to achieve with our future physicians, are we reflecting this in our admissions process? Are we appropriately encouraging diversity and different personalities who can achieve the same objectives (rather than privileging one type of person or personality)? Many community conversations reflected this as a key aspect of being able to work towards the shifts and changes we are making in the curriculum. Further, are we prepared to ask students to leave the program if they don’t measure up in terms of the values and attitudes that are expected? As well, the relative lack of family physicians was discussed. People were interested in how the decisions about seats for medical school are made and hope that their voices will be heard in terms of their needs. 12) Faculty participation Recognizing that role modeling and mentoring is an influence on students (even in case discussion and lectures), is enough attention being paid to the need for faculty orientation and participation such that the faculty can work well within the new curriculum and contribute to achieving the objectives? 13) Residency Is there an intention to examine our residency programs, in light of the curriculum renewal? 14) Additional skills/knowledge As mentioned above, much of the requisite knowledge and skills for physicians was assumed to be part of the curriculum. However, some aspects that were suggested could benefit from some additional attention include: o Nutrition – not in terms of becoming a nutritionist, but in having an increased appreciation and understanding of how important nutrition can be and encouraging patients to attend to this and/or refer to nutritionists o Termination of pregnancy, managing sexual assaults, and related aspects of care o Social determinants of health and an increased awareness of how poverty can both affect illness and the possibilities persons have for improving their health – as community members indicated, this is an important link to the value of social justice o Self-care – the value of and techniques/approaches for this; importantly linked to managing stress o Awareness and understanding of broader health professions – such as midwifery, massage therapy and naturopathy (which are regulated); the expectation is not to know everything about these areas, but to help break down some of the key stereotypes and misperceptions 8 o Increased focus on primary care, including prevention and promotion. This includes reflecting on the role of individual responsibility for health while not “blaming the victim” for their health issues o Skills at accepting and managing change – knowing change is a “given” within our health care system, are we helping to prepare our students for this? Conclusion: Potential Implications for the Curriculum As the previous section indicates, a number of suggestions for topic areas that could/should be considered for inclusion/expansion in the curriculum did arise in the community conversations. Overall, with the strongest themes being related to attentive communication, collaboration and humility, there is a depth and richness to what we heard from our community members. This information is valuable for helping to ensure that our future physicians are well-trained and that both they and we who are involved in designing and delivering the new curriculum aim for the ideals captured in the Overarching Objectives. Based on the community conversations and in addition to what is discussed above, some suggestions for the curriculum renewal process may include (but are not limited to): o Building rich cases – this may mean starting cases from the patient’s or family’s perspective or following a community member through a geriatric assessment in the home to what happens when he/she reaches the hospital. It may mean starting the case with being asked to provide a second opinion in a contentious case where the family and health care team are already at odds. In other words, how do we use cases to reflect the importance of attention and humility and send the message to our students that their skills in communication and collaboration are “just as” important as their diagnostic abilities in our cases? o Community involvement – when and how should we include members from the community in lectures, small group discussions, and case-based learning? o Demonstrating collaboration – how do we, as faculty, help to demonstrate the need for and value of collaboration? Do we work well together and with others from outside the FoM? o Evaluation methods – how might we need to change our evaluation methods to reinforce the messages of the new curriculum about the importance of certain attitudes and skills (such as communication skills)? o Developing a conflict of interest policy – knowing this work is already underway, having a strong policy in this regard will help to demonstrate both to our students and our community members that this is an important issue o What else? Ultimately, our community members are interested in and value the opportunity to contribute to ensuring “good” future physicians. We invite you to actively integrate the various themes identified to contribute to the various knowledge, skills and attitudes we are working towards with our future physicians. 9
"“Caring about and caring for – Personalizing the profession”"