J. Donald Boudreau

A healing curriculum.

Context  The banner of patient‐centredness flies over many academic institutions; however, the practice and teaching of medicine remain oriented to disease. This incongruence is the result of an original Flexnerian dichotomy between the basic and clinical sciences and is maintained by a more recent distinction between disease and illness. One mind‐set emphasises basic science and pathology pegadogically, whilst clinical medicine becomes a search for disease. The second introduces the patient as the focal point, underlining the personal and social contexts of illness.

Preparing medical students to become attentive listeners

Background: The ability to listen is critically important to many human endeavors and is the object of scholarly inquiry by a large variety of disciplines. While the characteristics of active listening skills in clinical practice have been elucidated previously, a cohesive set of principles to frame the teaching of these skills at the undergraduate medical level has not been described. Aims: The purpose of this study was to identify the principles that underlie the teaching of listening to medical students. We term this capacity, attentive listening. Methods: The authors relied extensively on prior work that clarified how language works in encounters between patients and physicians. They also conducted a review of the applicable medical literature and consulted with experts in applied linguistics and narrative theory. Results: They developed a set of eight core principles of attentive listening. These were then used to design specific teaching modules in the context of curriculum renewal at the Faculty of Medicine, McGill University. Conclusions: Principles that are pragmatic in nature and applicable to medical education have been developed and successfully deployed in an undergraduate medical curriculum.

The Osler Fellowship: an apprenticeship for medical educators.

Purpose As part of a renewed focus on the physician as healer and professional at McGill University, faculty members were recruited to teach in a four-year, longitudinal doctoring course called Physician Apprenticeship. The goal of this study was to examine the impact of this experience and the accompanying faculty development program on the teachers, known as Osler Fellows. Method An interviewer conducted semistructured interviews with 23 clinicians to understand their experiences as Osler Fellows and ascertain their views on how the workshop-based faculty development program, designed to mirror student experiences, differed from other professional development activities. Results The notion of connection and reconnection with the profession emerged as a major theme, consisting of four subthemes: the joy of working with students, the desire to make a difference, the process of reflection and renewal, and the building of community. Distinctive aspects of the faculty development program included the value of a common purpose, content that corresponded with core values, a sense of continuity, peer mentorship, and the emergence of a community of practice. Teachers also reported a sense of honor in being associated with Oslers name and a feeling of privilege in accompanying students on their journeys of discovery. Conclusions Participating in the Osler Fellowship, an example of situated and work-based learning, resulted in a sense of connection with students, medical education, core professional values, and colleagues. As medical educators continue to develop longitudinal mentoring programs, the authors hope that these findings will offer insights on faculty development, recruitment, and renewal.

The Humanities in Medical Education: Ways of Knowing, Doing and Being

The personhood of the physician is a crucial element in accomplishing the goals of medicine. We review claims made on behalf of the humanities in guiding professional identity formation. We explore the dichotomy that has evolved, since the Renaissance, between the humanities and the natural sciences. The result of this evolution is an historic misconstrual, preoccupying educators and diverting them from the moral development of physicians. We propose a curricular framework based on the recovery of Aristotelian concepts that bridge identity and activity. The humanities and the natural sciences, jointly and severally, can fulfill developmental, characterological and instrumental purposes.

The Foundation of Physicianship

Although the practice of medicine continually changes in response to new biomedical understanding, novel technologies, and evolving cultural contexts, the ethical foundations of the clinical relationship between patient and physician paradoxically remain constant. There are fundamental characteristics with respect to character, behavior, and responsibilities that are descriptive of and necessary to the role of healer and that underpin the notion of physicianship. This article discusses the underlying characteristics or virtues that are necessary to the practice of medicine from the perspectives of three different philosophic traditions: the Aristotelian idea of phronesis as developed in the work of Edmund Pellegrino; the notion of alterity as framed by Emmanuel Levinas; and the attributes necessary to healing as laid out in the kabbala.

Lost and Found in Translation: An Ecological Approach to Bilingual Research Methodology

Translation issues emerged from a qualitative study, conducted in French and English, that gathered patient perspectives on a newly implemented undergraduate medical curriculum entitled Physicianship: The Physician as Professional and Healer. French-speaking participants were interviewed using a translated interview guide, originally developed in English. A major finding that francophone participants contested the idea of the physician-healer in a manner not witnessed among the anglophone participants. Consultation with multilingual health professionals was undertaken to explore whether the contestation was the result of poor translation of the word healer. This process confirmed that no appropriate French equivalent could be found. With hindsight, the authors emphasize the importance of pretesting translated research instrumentation. An ecological perspective on language equivalency is also emphasized, in which emergent linguistic discrepancies are viewed as opportunities for learning about the culture-language relationship.

Preparing medical students to become skilled at clinical observation

Background: Observation is a fundamental skill for physicians and it is has been the subject of a resurgent interest. Although strategies for teaching observation have been described previously, many of them linked conceptually to emerging insights in visual literacy and aesthetic development, principles of clinical observation have not been elucidated. Aims: The purpose of this study was to develop a set of principles that would be useful in guiding educators teach medical students how to observe. Methods: The authors conducted a comprehensive review of the literature on the history and theory of clinical observation. They then consulted a group of individuals from a highly diverse background who, based on the nature of their work, were considered to have expertise in observation. Results: Informed by the literature and the group of experts, the authors developed a set of four guiding principles relating to pedagogy and eight core principles of clinical observation. In the context of curriculum renewal at the Faculty of Medicine, McGill University, these principles were then used to create specific teaching modules. Conclusions: Principles that are pragmatic in nature, anchored in a theoretical framework of visual competence and applicable to medical education have been developed and successfully deployed. Let someone say of a doctor that he really knows his physiology or anatomy, that he is dynamic–these are real compliments; but if you say he is an observer, a man who really knows how to see, this is perhaps the greatest compliment one can make. J.M. Charcot ()

Abraham Flexnerʼs “Mooted Question” and the Story of Integration

Contemporary medicine is characterized by dualities. They include psyche and soma, subject and object, and, most important, science and humanism. The authors, in exploring Flexners landmark publication, suggest that the history of curricular evolution has been marked by a quest for the integration of two knowledge bases: science and clinical medicine. They describe this goal as a preoccupation of medical educators, arguing that it was triggered, in part, by Flexners recommendation for a two-phase curriculum. Their claim is illustrated with an analysis of motives for curricular renewal at one medical school and a review of published reports from educational opinion leaders. They discuss Flexners conception of integration—namely, that unity could be achieved through methodology and, in particular, through inductive reasoning. They situate this perspective in the context of other purported integrative principles such as bioethics, narrative medicine, and the biopsychosocial model. They conclude by recommending an alternative framework for integration. The authors propose that a synthesis of two separate knowledge domains can be achieved through a common purpose and that, in a clinical context, that purpose is the well-being of the patient. Well-being is defined as the patients ability to pursue achievable goals and purposes. It can be brought about by changing medicines emphasis from the eradication of disease to the restoration of functions impaired by sickness. This idea is congruent with aspects of Flexners understanding of medical practice, as shown in his statement that the restoration of normal functioning should be the doctors “goal in action.”

A faculty development workshop in narrative-based reflective writing

Narrative approaches are used increasingly in the health professions with a range of objectives. We must acquaint educators with this burgeoning field and prepare them for the incorporation of story-telling in their pedagogical practices. The authors describe a template for a faculty development workshop designed to foster self-reflection through the use of narrative techniques and prepare clinical teachers to deploy such approaches. The design is based on a six-year experience in delivering introductory workshops in narrative approaches to medical teachers. The workshops, which served as a model for the template, have been offered to a total of 92 clinicians being trained to mentor medical students. A generic template is described. It includes a table of core concepts from narrative theory, a set of probing questions useful in a basic technical analysis of texts and a list of initiating prompts for exercises in reflective writing. A workshop organized and deployed using this template is deliverable over a half-day. The model has proven to be feasible and highly valued by participants. It can be adapted for other contexts by educators across the continuum of health professional education.

George Engel's Epistemology of Clinical Practice

George Engel’s (1913–1999) biopsychosocial model, one of the most significant proposals for the renewal of medicine in the latter half of the 20th century, has been understood primarily as a multi-factorial approach to the etiology of disease and as a call to re-humanize clinical practice. This common reading of Engel’s model misses the central aspect of his proposal, that the biopsychosocial model is an epistemology for clinical work. By stating the simple fact that the clinician is not dealing directly with a body, but first, and inevitably, with a person, Engel challenged the epistemology implicit in the classical clinical method—a method predicated on the possibility of direct access to the body. Framed in epistemological terms, the issue at stake is not the need to complement medical science with humane virtues, but rather to acknowledge that the object of clinical practice is not the body but the patient.