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As a prelude to facing the evolving roles and obligations of practising physicians, medical trainees are witness to the developments in the undergraduate and postgraduate curricula that reflect this evolution and are in keeping with increasingly recognized societal needs. The work of the CanMEDS 2000 Project (1) has yielded operationalized specialist physician roles to meet these needs. Launched in 1993 as an initiative of the Royal College of Physicians and Surgeons of Canada (RCPSC) Health and Public Policy Committee, the CanMEDS 2000 Project aimed to change the focus in specialty training from the abilities of the providers to the needs of society and to orient training programs to the needs of the population at large. It defines specialist roles based on needs assessment and consultation with the public and groups of health professionals; these activities identified the tasks and behaviours expected of physicians and operationalized them as roles. Success in fulfilling these roles requires physicians to master specific competencies incorporated as guideposts in the training and evaluation process of Canadian postgraduate trainees. CanMEDS has identified the following 7 roles: medical expert, communicator, scholar, collaborator, manager, health advocate, and professional. These roles can be thought of as clusters of competencies that a specialist physician should have. They form a framework that can be modelled and actively incorporated into the curricula of different medical schools and postgraduate programs across Canada. CanMEDS roles and competencies are not specific to a medical specialty or subspecialty but apply to all specialists, although specialties may emphasize some competencies more than others. In 2002, Canadian postgraduate training programs in psychiatry began to evaluate CanMEDS competencies formally. In-training evaluations are now structured based on the competencies, and the final examination has been modified to incorporate standardized stations designed to objectively evaluate candidate proficiencies in the competencies. It is therefore of great value for residents preparing for the certification examination in psychiatry to acquire the new conceptual model of training assessment aligned to the CanMEDS competencies. I shall now describe each of these roles and competencies and make some suggestions for acquiring each role’s competencies. RolesCandidates who meet the competencies key to the role of medical expert (that is, knowledge and procedures) are able to “Demonstrate diagnostic and therapeutic skills for ethical and effective patient care, access and apply information relevant to clinical practice, demonstrate effective consultation services with respect to patient care, education and legal opinion” (1). The medical expert role has long been the primary focus of medical training and is generally taught in lectures and clinical rounds format. The tradition of “reading around cases” in standard text and seminal literature has recently been formalized as problem-based learning. The apprenticeship model has been the cornerstone of clinical training: trainees acquire requisite skills working alongside experienced medical staff and clinicians with progressively increasing responsibility in regular inhospital work and teaching rounds, emergency and elective admissions, and in- and outpatient management and follow-up. While this model has stood the test of time, it can be enhanced by multidisciplinary community clinic experience wherein trainees can broaden their knowledge base through work with nonmedical professionals. For example, psychologists and experienced social workers can provide high-quality psychotherapy supervision in such evidence-supported therapies as dialectical behaviour therapy, cognitive-behavioural therapy, family therapy, and interpersonal therapy. Trainees can thus gain valuable psychotherapy skills in addition to the experience of interacting with patients outside the medical model. The training program also benefits from the expanded clinical teacher repertoire and perspective. Trainees can become familiar with the various medicolegal issues pertinent to psychiatry by preparing and participating in review board hearings; in the independent medical evaluation consultations often sought by third-party agencies, such as insurance companies; and in formal forensic psychiatry settings, such as court clinic diversion programs, where they exist. The key competencies for the communicator role are to “establish therapeutic relationship with patients and families, obtain and synthesize relevant history from patients, families and communities; listen effectively; discuss appropriate information with patients, families and health care team members” (1). What is the foundation of psychiatry, if not effective communication? While psychotherapy offers a unique context for communication, the daily business of virtually all aspects of psychiatric practice is replete with opportunities to hone skills in active, reflective listening, in rapport building, and in engaging in therapeutic relationships. Team and family meetings at either emergency or elective admission and at discharge planning for patients with serious mental illness are ideal occasions to identify and address issues raised by patients and families. Adroit communication is essential in situations where the family is directly involved in the treatment of incapable patients and in instances where the communication technique must be adapted to the needs of special populations. The key competencies of the scholar role are to “develop, implement and monitor a personal continuing education strategy; critically appraise sources of medical information; facilitate learning of patients, house staff, students and other professionals; contribute to the development of new knowledge” (1). Trainees who develop the habit of regular attendance at journal club meetings and critical appraisal rounds of the literature will acquire essential skills to pursue effective and efficient continuing medical education, which is of paramount importance if practising physicians are to maintain competence in the face of ongoing, rapid expansion of knowledge. Residents who take time to develop proficiency in evidence-based clinical decision making will enhance the efficacy of their independent practice. Throughout postgraduate training, residents often work closely with medical students as part of their regular duties or on-call requirements. These occasions are excellent opportunities to teach students (for example, by offering seminars) and thereby organize and crystallize the residents’ own knowledge. Trainees who participate in clinical research or quality-monitoring projects appreciate the scope of empirical evaluative research as well as its limitations. Those who can skillfully develop and test hypotheses, conduct objective outcome evaluations, and review findings in an organized fashion can actively incorporate and apply research principles to continuously evaluate and improve clinical practice and share findings in professional and scientific fora and literature. The key competencies of the collaborator role are “to consult effectively with other physicians and health care professionals; contribute to interdisciplinary team activities”(1). The multidisciplinary team approach to treatment is the perfect vehicle for enhancing collaboration skills in the course of team rounds; for developing, implementing, monitoring, and adjusting care plans; and for networking with community agencies and institutions. Shared care and consultations to family physicians and community agencies offer opportunities for first-hand collaborative experiences. Consultation- liaison, geriatric and chronic care rehabilitation, and community outreach rotations often have a strong component of interdisciplinary and interagency collaboration. Trainees are strongly advised to make use of these opportunities to develop key collaborator competency. The competencies of the manager are “to use resources to balance patient care, learning needs and outside activities; allocate final health care resources wisely; work effectively and efficiently in a health care organization; use information and technology to optimize patient care and life long learning” (1). Rotation experience in underserviced areas often highlights the essential issues in resource identification and management and may expose trainees to practical and creative solutions and community initiatives. Trainees on a hospital- or community agency–based rotation may participate in program planning, program review committees, strategic planning committees, program evaluation, and operational reviews of critical incidents, thus gaining familiarity with the operation and management of the health care organization. Residents are encouraged to seek out these training opportunities. The competencies within the role of health advocate are defined as follows: “to identify the important determinance of health affecting patients; contribute to improved health of patients in communities; and respond to those issues where advocacy is appropriate” (1). Trainees who are sensitive communicators will become aware of unique health-related issues faced by patients and their families. Work with such community agencies as the Canadian Mental Health Association can highlight particular issues identified in the community. Trainees who develop awareness of such structures of governance and mental health care as mental health legislation and the legal, economic, and societal perspectives on mental illness gain a broad understanding of the complex individual and community factors that create the context for, and colour the experience, expectations, and reactions of, patients, families, and communities. The key competencies of the professional role are “to deliver the highest quality care with integrity, honesty and compassion; exhibit proper personal and interpersonal professional behaviours; practice medicine that is ethically consistent with the obligations of a physician” (1). At the very least, satisfactory fulfillment of the professional role will promote patient satisfaction. At best, professionals will be an example to their community and inspire future trainees. While rounds on medical ethics and medicolegal issues can provide a didactic foundation, integration of high professional standards into daily clinical work is an ongoing process for which a supportive training environment is essential. Trainees who can ensure that patient well-being is given priority in treatment decisions and who are able to consistently maintain clear professional boundaries and high personal ethical standards in keeping with the Hippocratic Oath are well underway to meeting the professional role requirements. A balanced lifestyle is also essential to ensure optimum performance. Trainees who develop and maintain professional self-awareness will recognize the limitations of their own knowledge and will be able to seek assistance when needed. In the foregoing, I have outlined a few strategies for postgraduate trainees to acquire competencies needed to master the CanMEDS roles and to be prepared for the current comprehensive objective certification examination of the RCPSC. Trainees with initiative and vision, capacity for self- reflection, and desire for ongoing professional self- improvement will find many opportunities within a training program to incorporate the CanMEDS roles. Program directors and supervisors also need to work collaboratively with residents to arrange creative and flexible opportunities to assist them in acquiring the CanMEDS roles. Reference1. Societal Needs Working Group. CanMEDS 2000 project. Skills for the new millennium. Annals of the Royal College of Physicians and Surgeons of Canada 1996;29:206–16. Author(s)Manuscript received and accepted March 2003. 1. Consultant Psychiatrist, Schizophrenia Treatment and Research Program, Regional Mental Health Care, London, Ontario. Address for correspondence: Dr I Tuhan, Schizophrenia Treatment and Research Program, Regional Mental Health Care, London, 850 Highbury Avenue, London, ON N6A 4H1 e-mail: izzy.tuhan@sjhc.london.on.ca
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