Focus on the profession: Academic and clinical departments

The BC government has fund­ed a provincial medical school linked to one provincial and five regional health authorities. Unique in Canada, this structure provides an unprecedented opportunity for improvement in the health and health care of British Columbians. 

Appropriate training of new physicians and the support of these physicians in clinical practice, academic pursuits, and leadership will define the degree of success we have in sustaining and improving on health care. The challenges in medical education are significant and are related directly to changes that have occurred in the health care system during the last 30 years. 

They are not unique to BC, as demonstrated by recent calls for broad educational reform to meet the realities of medical practice today.[1,2] In a recent study, the Institute of Medicine noted that “education will require the greatest changes in the coming decade” and that education is “one of the primary mechanisms for initiating a cultural shift toward an emphasis on the needs of patients and populations and a focus on improving health, using the best of science and the best of caring.”[3] 

This cultural shift is expressed through how we function as a profession. Professions are “complex social structures derived from the guild system of specialized competences, intended to organize specialized and complex bodies of knowledge in such a way as to address both individual and societal needs.”[4] 

For physicians this encompasses a moral and ethical framework and the knowledge, practices, and behaviors that define professionals and as such the relationship they have to their patients, to their colleagues, and to the broader society. 

Departments are the structure through which professional function is organized and supported, whether that is clinical departments within hos­pitals, academic de­partments within the Faculty of Medicine, or departments that bridge the university and clinical environments of the major teaching hospitals. 

At their core, these departments share common responsibilities supporting professionalism: credentials, standards of practice, collegial relations, continuing professional de­velopment, and quality improvement.

Medical students do not become professionals in the classroom. They become professionals through mentored engagement in all aspects of professional practice.[5] As argued by Stern and Papadakis, “students need to see that professionalism is articulated throughout the system in which they work and learn… this means providing an environment that is consistently and clearly professional not only in medical school but throughout the entire system of care.”[6] 

So how effective are departments in supporting education and how can we do an even better job? Four stra­te­gies can move us in the right direction:

• Make professionalism the tie that binds the Faculty of Medicine and the health authorities.
• Engage clinical and academic de­partments as key drivers of professionalism.
• Ensure knowledge development and continuous learning are recognized as central to professionalism.
• Challenge government to focus on supporting professionalism.

Make professionalism the tie that binds 
Whether we are educating students or delivering the best quality of care, the message from the literature is clear: We need to focus on building and supporting professionalism. During the last 30 years the social contract with physicians has changed as the health care system has changed. 

Physicians are no longer “practising together alone”; instead they have moved away from “professional values and training based on an individualistic orientation” to function as members of “large, complex organizations. Little training is given to equip doctors for this, and the difficulty that many consequently experience leads to stress and frustration.”[7]

The Faculty of Medicine, organizations such as the BCMA and the College of Physicians and Surgeons of BC, and the health authorities need a common vision of professionalism as they support physicians moving along the continuum from medical education to practice to retirement. There should be agreement that professionalism is central to the success of the Faculty of Medicine and the health care system, and that it is the tie that binds.

Engage clinical and academic departments
In BC we have a large number of clinical departments beyond the university structures. They are involved in the organization and delivery of services to a significant degree. Expansion of the medical school has thrust on them a whole new relationship that adds complexity and has clearly been challenging. 

Most of the focus in the early years of medical school expansion and distribution has been on trying to address the impact of having more trainees on delivery of clinical services, issues around the coordination of academic appointments, challenges around collaborative recruitment, and the logistics of housing the educational enterprise. 

There have been tensions between some of the academic departments and the hospital-based clinical departments. This is to be expected given the different mandates, the different governance structures, and the different pressures being experienced. The clinical departments are challenged by the complexity of issues related to patient care, access to resources such as operating room time, and appropriate compensation for the teaching they provide. 

At the same time, UBC de­partments have suddenly faced a complex set of new challenges—how to deliver and ensure a high-quality curriculum using a distributed model. The UBC basic science departments have more specific challenges. While basic science is integrated into much of the curriculum through problem-based learning, a broad range of content and expertise needed by medical students remains outside the curriculum.

Perhaps it is time for department leadership across the clinical and academic spectrum to think differently about how they work together. By supporting students in medical school and physicians in practice they can become the key drivers of professionalism.

Ensure knowledge development and continuous learning 
Continuous learning is an individual responsibility, but departments play a key role in creating and supporting the environment for continuous learning and quality improvement. 

It is important to think about how departments can support new knowledge development and the translation of this knowledge into practice. Integrating the medical school with the expertise in the community can provide the opportunity to develop innovative learning and continuous improvement strategies.

Challenge government 
The BC government has created an important public policy experiment. To take this experiment further, both government and health authorities need to move from seeing physicians as “practising together alone” to seeing them as leaders and change agents for progress. 

They also need to recognize that departments have a central role to play. The recent agreement between the government and the BCMA is a positive example of moving beyond compensation issues to supporting physician engagement and leadership in the organization and delivery of health care.

Summary
The expansion and distribution of the undergraduate and postgraduate medical programs, combined with the regionalization of health care and a renewed focus on the quality and safety of health care, provides an unprecedented opportunity for improvement and national and international lead­ership. Professionalism is central to this major public policy experiment. While education and clinical and research services may be delivered in multidisciplinary settings, the development and support of professionals is achieved through the discipline of departments. We must support and strengthen departments and encourage stronger working relationships among them.

Competing interests
None declared.

Clinical faculty: Growing, changing, and responding
There is something magical and inspiring about the eagerness of students to learn and their willingness to devote countless hours and much effort to mastering the skills required to be physicians. 

Students humble us with their knowledge of current innovations, spur us on with their questions, and challenge us to explain and transmit what it is we do when we practise the science and the art of medicine.  

Understanding these students and what it takes to transform their newly minted skills and ideas into astute practice is the fundamental territory of clinical teaching, much of which is provided by clinical faculty.  

Since the inception of the Faculty of Medicine at the University of British Columbia, there has been a deliberate inclusion of and reliance on clinical faculty members to translate and transform classroom learning into medical practice at the bedside and in the consultation room. 

The number of clinical faculty is breathtaking: at UBC there are more than 3500 clinical teachers, and at least 3000 of those are physicians. 

Clinical instructors are governed by an appointment offer/letter that grants them independent contractor status; they are not usually employees of the university. 

Attracting, honoring, rewarding, and retaining the devoted clinical faculty members who provide professional academic activities in education, administration, and research in the faculty is a challenge. 

This challenge becomes difficult to meet when many of the desired “rewards,” such as increased access to health authority and patient care resources, are not regulated by the Faculty of Medicine, and when personnel shortages, wait times, and accountability measures have pushed many practitioners to their limit. 

This challenge is not unique to UBC: it is seen across the country and discussed at international meetings. 

However, many new initiatives aimed at recognizing clinical faculty have been put in place: examples include the creation of the Office of Clinical Faculty Affairs; the development of a new contract for clinical faculty with recognition for teaching at the undergraduate and postgraduate levels; the creation of a Faculty of Medicine and BCMA venue for discussing general matters of joint interest; and the formation of a clinical teaching subcommittee.  

These initiatives demonstrate some of what is being done to make the intersection of clinical faculty with the faculty easier and more enjoyable.  

While there are still many hills to climb in this process, substantial strides have been made—strides that have improved matters for clinical faculty in all spheres of their work, teaching, research, and administration. 

The nature and pace of the mandated medical program expansion have presented opportunities and challenges. Its success to date is in large part due to the growing cohort of clinical faculty members across BC who blend teaching with patient care.  

Working with clinical faculty to support each component will be important to the continued success of this initiative. 

—Katherine Paton, MD, FRCSC
Special Advisor to the Dean on Clinical Faculty Affairs, Faculty of Medicine, UBC
Clinical Professor, Department of Ophthalmology and Visual Sciences, UBC

Dr Armstrong is an associate professor and head of the Department of Pediatrics in the Faculty of Medicine, UBC. He is also chief of Pediatric Medicine for BC Children’s Hospital, Sunny Hill Health Centre for Children, and BC Women’s Hospital, and  head of Paediatrics for St. Paul’s Hospital and Providence Health Care.