Seeking Equanimity:
Sir William Osler
and
Competence by Design
Sharon E Card
Canadian Society of Internal Medicine October 2016
[email protected]
@sharon_cards
Learning Outcomes
1. Describe the Royal College
of Physician and Surgeon’s
Competence by Design
(CBD) initiative.
2. List the ways that the CBD
initiative will impact
General Internal Medicine
(GIM) postgraduate
training.
3. Compare and contrast the
future of GIM education
with postgraduate training
in the time of Sir William
Osler.
Source of Images – Osler Library
Canadian Society of Internal Medicine
Annual Meeting 2016
Montreal, QC
The following presentation represents the views of the speaker
at the time of the presentation. This information is meant for
educational purposes, and should not replace other sources
of information or your medical judgment.
Sharon E. Card. Osler Lecture
What is Competence by Design (CBD)?
• “The CBD initiative will transition specialist
medical education from a traditional timebased model to a hybrid form of competencybased medical education (CBME). CBD is a
multi-year transformational change initiative”.
•
RCPSC Website - http://www.royalcollege.ca/rcsite/cbd/competence-by-design-cbd-e
Why Change?2,3
“that
the direction in which
education starts a man will
determine his future life.”
Plato, Republic, iv. Jowett’s translation. As quoted by Osler
in Aequanimitas Page 22.
Pillars of CBD*
1.
2.
3.
4.
5.
Clear articulation of Graduates Outcomes
Deliberate Entrustment
Learning in Authentic Environments
Facilitated Learner Continuous Improvement
Program of Assessment
* According to S. Card.
One - Clear Articulation of Graduates
Outcomes.
“Competency-based Medical Education is an
approach to preparing physicians for practice
that is fundamentally oriented to graduate
outcome abilities and organized around
competencies derived from an analysis of
societal and patient needs.”
Frank et al. 4
Building a General Internist5-9
Roof = Adapted to Context
Acute and Critical Illness






Chronic Illness
Common
Emergent
Multisystem
Undifferentiated
Autonomous AND Safe
With Stressors
 Pregnancy & Surgery





GIM Approach = Foundation








Patient not organ centered
Optimize not maximize care
Holistic and Comprehensive
Evidence (intelligence) informed
Anticipate and Coordinate
Collaborative Practice
Adapt to context
Life Long Learner
Preventive Care
Single or Multiple
Competing priorities
Uncertainty
Ambiguity
Diversity of Contexts
System Skills
Team Skills
21st Century Patient
Societal Expectations
Information Technology
Leadership
“on the absence of the sense of responsibility
which permitted a criminal laxity in medical
education unknown before in our annals.”
Sir William Osler2
Two – Deliberate Entrustment10
Entrustable Professional Activity
(EPA)10
Not
Assessed
Does Not
Meet
MEDICAL EXPERT
Knowledge of
Anatomy
COMMUNICATOR
Informed Consent
COLLABORATOR
Collaborates with
nurses
ADVOCATE
Uses procedure
wisely
PROFESSIONAL
Knows limits
Meets
Exceeds
• I entrust this resident to
perform ABGs
unsupervised.
Yes
No
“One of the chief reasons for this uncertainty
is the increasing variability in the
manifestations of any one disease”.
Sir William Osler. 2
Undoing the Pixelation
of
Medical Education.
13
Three – Learning in Authentic
Environments.
• “Ask any physician of twenty
years’ standing how he has
become proficient in his art,
and he will reply, by constant
contact with disease; and he
will add that the medicine he
learned in the schools was
totally different from the
medicine he learned at the
bedside.”
• “the best teaching is that
taught by the patient himself.”
• Sir William Osler. 2
Source of Images – Osler Library
What is “Service”?
• “contribution to
the welfare of
others”
• Merriam Webster
Dictionary
• Service demands
must not interfere
with the ability of
the residents to
follow the
academic
program.
• RCPSC “B” Accreditation
Standards.
• “I desire no other epitaph – no hurry about it,
I may say – than the statement that I taught
medical students in the wards, as I regard this
as by far the most useful and important work I
have been called upon to do.”
• Sir William Osler2
Four – Facilitated Learner Continuous
Improvement11-16
Sir William Osler2
Educational Alliance 11-16
“More perhaps than any other professional man,
the doctor has a curious – shall I say morbid? –
sensitiveness to (what he regards) personal error.
In a way this is right; but it is too often
accompanied by a cocksureness of opinion
which, if encouraged, leads him to so lively a
conceit that the mere suggestion of mistake
under any circumstances is regarded as a
reflection on his honour, a reflection equally
resented whether of lay or of professional origin.
Sir William Osler2
Start out with the conviction that absolute truth is hard
to reach in matters relating to our fellow creatures,
healthy or diseased, that slips in observation are
inevitable even with the best trained faculties, that
errors in judgment must occur in the practice of an art
which consists largely of balancing probabilities; - start, I
say, with this attitude in mind, and mistakes will be
acknowledged and regretted but instead of a slow
process of self-deception, with ever increasing inability
to recognize truth, you will draw from your errors the
very lessons which may enable you to avoid their
repetition.”
Sir William Osler2
Five – Program of Assessment.
“To cover the vast field of medicine
in four years is an impossible task.
We can only instil principles, put
the student in the right path, give
him methods, teach him how to
study, and early to discern between
essentials and non-essentials”.
“Perfect happiness for student and
teacher will come with the
abolition of examinations, which
are stumbling blocks and rocks of
offence in the pathway of the true
student”.
Sir William Osler2
Source of Images – Osler Library
Program of Assessment
• “and the degree could be
safely conferred upon
certificates of
competency, which would
really mean a more
thorough knowledge of a
man’s fitness than can
possibly be got by our
present system of
examination.”
• Sir William Osler2
Source of Images – Osler Library
Why Change?
1. Clear articulation of
Graduates Outcomes
2. Deliberate Entrustment
3. Learning in Authentic
Environments
4. Facilitated Learner
Continuous
Improvement
5. Program of Assessment
1. Meet societal needs.
2. Focus training on tasks
3. Back to the bedside –
one’s future career.
4. Educational Alliance.
5. Avoid high stakes exams
as main measurement of
attainment of
competency.
McGill University Faculty of Medicine at its Semicentennial, 1882
Standing, from left to right, are Thomas G. Roddick, George Ross, William E. Scott, William Osler, Francis J. Shepherd, William Gardner, George
W. Campbell, Gilbert Prout Girdwood, Frank Buller, and Richard L. MacDonell. Sitting, from left to right, are Robert Palmer Howard, William
Wright, John William Dawson, Duncan C. MacCallum, Robert Craik, and George E. Fenwick.
Source of Images – Osler Library
Era of General Internal Medicine
• Leaders in:
 Adaptability
 Relationships
 Systems Engineering
 Education
 Patient Safety
 Complex Care
 Wellness, Resilience
 And More…
Source of Images – Osler Library
Building a General Internist5-9
Roof = Designed for Complexity
Trained for individual competency
AND able to practice and lead
collectively
Acute and Critical Illness






Chronic Illness
Common
Emergent
Multisystem
Undifferentiated
Autonomous AND Safe
With Stressors
 Pregnancy & Surgery





GIM Approach = Foundation








Patient not organ centered
Optimize not maximize care
Holistic and Comprehensive
Evidence (intelligence) informed
Anticipate and Coordinate
Collaborative Practice
Adapt to context
Life Long Learner
Preventive Care
Single or Multiple
Competing priorities
Uncertainty
Ambiguity
Aequanimitas2
“Imperturbability
means coolness and
presence of mind under all circumstances,
calmness amid storm, clearness of judgment
in moments of grave peril, immobility,
impassiveness, or, to use an old and
expressive word, phlegm. It the quality
which is most appreciated by the laity
though often misunderstood by them; and
the physician who has the misfortune to be
without it, who betrays indecision and
worry, and who shows that he is flustered
and flurried in ordinary emergencies, loses
rapidly the confidence of his patients.”
“In a true and perfect form, imperturbability
is indissolubly associated with wide
experience and intimate knowledge of the
varied aspects of disease.”
Source of Images – Osler Library
William Osler's Carte de Visite, October, 1881
Quoting Oceanus Sir William Osler2
Thanks to:
 Dr. Robert T. Card for lending me his copy of
Aequanimitas given on his graduation in 1964.
 Niklos and Scott.
 The Sir William Osler Library for permission to
reproduce the pictures in this talk.
https://www.mcgill.ca/library/branches/osler
 Canadian Society of Internal Medicine.
 A multitude of people in this room that are true
physicians dedicated to improving their patients’
care current and future.
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References:
Royal College Website - http://www.royalcollege.ca/rcsite/cbd/competence-by-design-cbd-e.
Aequanimatas. Sir William Osler McGraw Hill. 1907.
Asch DA, Nicholson S, Srinivas SK, Herrin J, Epstein AJ. How Do You Deliver a Good Obstetrician? Outcome-Based Evaluation of Medical
Education. Acad Med. 2014 89(1): 24-26.
Frank JR, Mungroo R, Ahmad Y, et al.Toward a definition of competency-based education in medicine: A systematic review of published
definitions. Med Teach. 2010;32:631–637.
Card SE, Snell L, O’Brien B. Are Canadian General Internal Medicine training program graduates well prepared for their future careers?
BMC Medical Education 2006; 6: 56. Pages 1 – 9
Card SE, PausJenssen AM, Ottenbreit RC. Determining specific competencies for General Internal Medicine residents (PGY 4 and PGY 5).
What are they and are programs currently teaching them? A survey of practicing General Internists.
Card SE, Ward HA, Broberg L. Preparing General Internal Medicine Residents for the Future – Aiming to Match Training to Need – A
Pilot Study in Saskatchewan. CJGIM 2016 11(2): 26 – 30.
Card SE, Kassam N. The Future is Bright for Competency-based Education in General Internal Medicine CJGIM 2016 11(1): 25 – 29.
The current Royal College documents (objectives of training, specialty training requirements and specific standards of accreditation for
Internal Medicine and General Internal Medicine) can be accessed at: http://www.royalcollege.ca/portal/page/portal/rc/public.
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Voyer S et al. Investigating conditions for meaningful feedback in the context of an evidence-based feedback programme. Med Ed.
2016; 50: 943-954.
Hauer KE. Evaluating the value of direct observation for learning: the limits of autonomy. Med Ed. 2016; 50: 992-996.
Watling C, LaDonna KA, Lingard L, Voyer S ,Hatala R. “Sometimes the work just needs to be done”: socio-cultural influences on direct
observation in medical training. Med Ed 2016; 50: 1054-1064.
Watling C, Driessen E, Van Der Vleuten CPM et al. Beyond individualism: professional culture and its influence on feedback. Med Ed
2013; 47: 585-594.
Watling C, Driessen E, Van der Vleuten CPM et al. Music lessons: revealing medicine’s learning culture through a comparison with that
of music. Med Ed. 2013; 47: 842-850.
Hubinette MM, Regehr G, Cristancho. Lessons from Rocket Science: Reframing the Concept of the Physician Health Advocate. Acad.
Med. 2016; 91: 1344-1347.
Holmboe ES and Batalden P. Achieving the Desired Transformation:Thoughts on Next Steps for Outcomes-Based Medical Education.
Acad Med. 2015;90:1215–1223.