American Medical Education 100 Years After the Flexner Report

The new england journal of medicine

review Article

Medical Education

Malcolm Cox, M.D., and David M. Irby, Ph.D., Editors American Medical Education 100 Years after the Flexner Report

Molly Cooke, M.D., David M. Irby, Ph.D., William Sullivan, Ph.D., and Kenneth M. Ludmerer, M.D.

edical education seems to be in a perpetual state of unrest. From the Department of Medicine, Uni- From the early 1900s to the present, more than a score of reports from versity of California, San Francisco, San Francisco (M.C., D.M.I.); the Carnegie Mfoundations, educational bodies, and professional task forces have crit- Foundation for the Advancement of icized medical education for emphasizing scientific knowledge over biologic under- Teaching, Stanford, CA (M.C., D.M.I., W.S.); standing, clinical reasoning, practical skill, and the development of character, com- and the Department of Medicine, Wash- ington University, St. Louis (K.M.L.). passion, and integrity.1-4 How did this situation arise, and what can be done about it? In this article, which introduces a new series on medical education in the Journal, N Engl J Med 2006;355:1339-44. we summarize the changes in medical education over the past century and describe Copyright © 2006 Massachusetts Medical Society. the current challenges, using as a framework the key goals of professional education: to transmit knowledge, to impart skills, and to inculcate the values of the profession.

Abraham Flexner and American Medical Education

Almost a century ago, Abraham Flexner, a research scholar at the Carnegie Founda- tion for the Advancement of Teaching, undertook an assessment of medical education in North America, visiting all 155 medical schools then in operation in the United States and Canada. His 1910 report, addressed primarily to the public, helped change the face of American medical education.5-7 The power of Flexner’s report derived from his emphasis on the scientific basis of medical practice, the comprehensive nature of his survey, and the appeal of his message to the American public. Although reform in medical education was already under way, Flexner’s report fueled change by criticizing the mediocre quality and profit motive of many schools and teachers, the inadequate curricula and facilities at a number of schools, and the nonscientific approach to preparation for the profession, which contrasted with the university-based system of medical education in Germany. At the core of Flexner’s view was the notion that formal analytic reasoning, the kind of thinking integral to the natural sciences, should hold pride of place in the intellectual training of physicians. This idea was pioneered at Harvard University, the University of Michigan, and the University of Pennsylvania in the 1880s but was most fully expressed in the educational program at Johns Hopkins University, which Flexner regarded as the ideal for medical education.8 In addition to a scientific foundation for medical education, Flexner envisioned a clinical phase of education in academically oriented hospitals, where thoughtful clinicians would pursue research stimulated by the questions that arose in the course of patient care and teach their students to do the same. To Flexner, research was not an end in its own

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cation was the integration of investigation with teaching and patient care. Teaching, clinical care, and investigation each served the others’ purpos- es, because most research was based on the direct examination of patients. Gifted clinical investigators tended to be equally gifted as clinicians and clinical teachers. After 1960, however, as medical research became increasingly molecular in orientation, patients were bypassed in most cutting- edge investigations, and immersion in the laboratory became necessary for the most prestigious scientific projects. Clinical teachers found it increasingly difficult to be first-tier researchers, and fewer and fewer investigators could bring the depth of clinical knowledge and experience to teaching that they once had.10 The increasing turbulence of the health care environment in the past 20 years has generated a second set of conditions inimical to medical education as Flexner imagined it. Clinical teachers have been under intensifying pressure to in- crease their clinical productivity — that is, to generate revenues by providing care for paying 11-13 Abraham Flexner. patients. As a result, they have less time avail-

Courtesy of the Carnegie Corporation of New York. New of Corporation Carnegie the of Courtesy able for teaching, often to their immense frustra- tion. In addition, the harsh, commercial atmo- right; it was important because it led to better sphere of the marketplace has permeated many patient care and teaching. Indeed, he subscribed academic medical centers. Students hear institu- to the motto, “Think much; publish little.”9 tional leaders speaking more about “throughput,” “capture of market share,” “units of service,” and Transformation of Medicine the financial “bottom line” than about the preven- in the 20th Century tion and relief of suffering. Students learn from this culture that health care as a business may The academic environment has been transformed threaten medicine as a calling. since Flexner’s day. In academic hospitals, research Thus we arrive at our current predicament: quickly outstripped teaching in importance, and medical students and residents are often taught a “publish or perish” culture emerged in American clinical medicine either by faculty who spend very universities and medical schools. Research produc- limited time seeing patients and honing their clini- tivity became the metric by which faculty accom- cal skills (and who regard the practice of medicine plishment was judged; teaching, caring for patients, as a secondary activity in their careers) or by teach- and addressing broader public health issues were ers who have little familiarity with modern bio- viewed as less important activities. Thus, today’s medical science (and who see few, if any, academic subordination of teaching to research, as well as rewards in leaving their busy practices to teach). In the narrow gaze of American medical education either case, many clinical teachers no longer ex- on biologic matters, represents a long-standing emplify Flexner’s model of the clinician-investi- tradition.8 gator. In addition to the shift in the importance of research relative to teaching and patient care, a Learning Medicine as transformation in the process of research on hu- Professional Education man disease has contributed to our current state of affairs. For the first half of the 20th century, All forms of professional education share the goal a distinctive feature of American medical edu- of readying students for accomplished and respon-

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Downloaded from www.nejm.org by JULIO H. PENAFFFORT MD on October 12, 2006 . Copyright © 2006 Massachusetts Medical Society. All rights reserved. medical education sible practice in service to others. Thus, profes- that every patient deserves the best possible care, sionals in training must master both abundant we are challenged to provide appropriate oppor- theory and large bodies of knowledge; the final tunities for experiential learning and practice test of their efforts, however, will be not what they while meeting the service demands of teaching know but what they do. The purpose of medical hospitals. The educational mission of teaching hos- education is to transmit the knowledge, impart pitals is further compromised by the absence of the skills, and inculcate the values of the profes- performance standards and assessment methods sion in an appropriately balanced and integrated that can clearly establish that learners are ready manner.14,15 In the apprenticeship model of medi- to advance to the next level of independence and cal training that prevailed into the mid-19th cen- challenge. tury, student physicians encountered this knowl- The moral dimension of medical education re- edge and these skills and values as enacted by quires that students and residents acquire a cru- their teachers in the course of caring for patients. cial set of professional values and qualities, at the How are knowledge, skills, and professional val- heart of which is the willingness to put the needs ues represented in contemporary medical edu- of the patient first. A generation ago, the hours cation? worked served as a simple proxy for dedication to The way in which students encounter the knowl- patients; now, an appropriate concern for the well- edge base of medicine has been profoundly in- being of trainees and the safety of their patients fluenced, as Flexner intended, by the assimilation demands a new understanding of what it means of medical education into the culture of the uni- to be dedicated to one’s patients.19 Professional versity. Theoretical, scientific knowledge formu- values are continuously exemplified and enacted lated in context-free and value-neutral terms is in the course of medical education through role seen as the primary basis for medical knowledge modeling, setting expectations, telling stories and and reasoning. This knowledge is grounded in parables, and interacting with the health care the basic sciences; the academy accommodates environment, not just in courses on ethics and less comfortably the practical skills and distinct patient–doctor communication. However, the val- moral orientation required for successful practice ues of the profession are becoming increasingly in medicine. However, Flexner had not intended difficult for learners to discern; the conclusions that such knowledge should be the sole or even they draw, as they witness the struggle of under- the predominant basis for clinical decision mak- insured working people to obtain health care, ing.5 Within 15 years after issuing his report, marked differences in the use of expensive tech- Flexner had come to believe that the medical cur- nologies in different health care environments, riculum overweighted the scientific aspects of and their physician-teachers in complicated rela- medicine to the exclusion of the social and hu- tionships with companies that make health care manistic aspects. He wrote in 1925, “Scientific products, should concern us. medicine in America — young, vigorous and Not only has the knowledge base for medical positivistic — is today sadly deficient in cultural practice hypertrophied since Flexner’s day, but the and philosophic background.”16 He undoubtedly delivery of care has also become vastly more com- would be disappointed to see the extent to which plicated, and the expectations of the public higher. this critique still holds true. However, it has been difficult to integrate the Responsibility for the care of patients is a pow- new skills, knowledge, and attitudes required for erful stimulus for learning,17 and active learning proficient practice into medical education at both requires that clinical skills, both cognitive and the predoctoral and residency levels. Although procedural, be attained through the supervised many students and residents are interested in provision of patient care. As Flexner recognized, learning about interprofessional teamwork, pop- medical novices require the opportunity to practice ulation health, and health policy and the organi- skills under the guidance of experienced teach- zation of health services, these topics tend to be ing physicians until they attain a high level of poorly represented in medical school and resi- proficiency. Increasing attention to the quality of dency curricula. It can be hard to teach messy care, patient safety, and documentation of care real-world issues, but practitioners need to un- enhances medical practice18 but threatens to rele- derstand how these issues affect their patients and gate trainees to the role of passive observer. Given how to interact with, and ultimately improve, an

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exceedingly complex and fragmented system to The groundwork that has been laid by explicit provide good patient care. instruction in professionalism, combined with effective role modeling and attention to the hid- Preparing Physicians den curriculum of the practice environment, can for the 21st Century support the development of a comprehensive and sophisticated understanding of professional ed- What can be done to bring the knowledge, skills, ucation.22 Sociologists have noted the impor- and values that must be imparted by medical edu- tance of socialization and implicit learning in cation into better balance and to prepare outstand- the development of professional attitudes and ing physicians for the 21st century? As the arti- behaviors.23 cles in this series will illustrate, the solutions are It has long been observed that assessment apparent for some problems, but medical schools drives learning. If we care whether medical stu- and the institutions that sponsor residency pro- dents and residents become skillful practitioners grams need to develop the will to implement them. and sensitive and compassionate healers, as well Other problems are more complex, and their solu- as knowledgeable technicians, our approaches tions more uncertain. With respect to medical to the evaluation of learners must reach beyond knowledge, the gaps between what we know about knowledge to rigorously assess procedural skills, how people learn and how medicine is currently judgment, and commitment to patients. Self-assess- taught can be corrected. Cognitive psychology has ment, peer evaluations, portfolios of the learner’s demonstrated that facts and concepts are best re- work, written assessments of clinical reasoning, called and put into service when they are taught, standardized patient examinations, oral examina- practiced, and assessed in the context in which tions, and sophisticated simulations are used in- they will be used.20 Several decades of research on creasingly to support the acquisition of appropriate clinical expertise have elucidated the thinking of professional values as well as knowledge, rea- physicians as they evaluate signs and symptoms, soning, and skills. Rigorous assessment has the select and interpret diagnostic tests, and synthesize potential to inspire learning, influence values, re- data to develop clinical assessments and care plans; inforce competence, and reassure the public.24 these insights can be shared with learners as well Much of what we know about effective inter- as their teachers.21 ventions is not translated from research settings The acquisition of skills for practice requires into everyday patient care. Increasing emphasis is radical transformation. Although the dictum “see being placed on evidence-based practice, systems one, do one, teach one” may have characterized approaches, and quality improvement. Advances the way in which clinical skills were learned in in these areas require the ability to integrate sci- the past, it is now clear that for training in skills entific discoveries and context-specific experimen- to be effective, learners at all levels must have the tation for the continuous improvement of the opportunity to compare their performance with processes of medical practice. New paradigms a standard and to practice until an acceptable that connect these processes are emerging, and level of proficiency is attained. An appreciation they have the potential to revolutionize both the of the importance of practice and the honest ad- way in which people learn and the environment mission that neophytes cannot perform high- in which learning takes place.25 stakes procedures at an acceptable level of proficiency demand that we develop approaches to Finding the Will to Change skills training that do not put our patients at risk in service to education. The use of increas- The need for a fundamental redesign of the con- ingly sophisticated simulations and virtual real- tent of medical training is clear. In some instances, ity offers physicians at all levels the opportunity the road that needs to be taken is also clear — for to refresh skills and learn new ones in a safe prac- example, more emphasis should be placed on the tice environment. Educational methods that al- social, economic, and political aspects of health low the demonstration of mastery at one level, care delivery. However, curricular reform is never with respect to both technique and judgment, simple or easy, and “turf battles” are inevitable. before progression to the next level teach an im- The challenge is not defining the appropriate con- portant lesson in professionalism as well. tent but rather incorporating it into the curricu-

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Downloaded from www.nejm.org by JULIO H. PENAFFFORT MD on October 12, 2006 . Copyright © 2006 Massachusetts Medical Society. All rights reserved. medical education lum in a manner that emphasizes its importance ing properly, if they choose to use the funds for relative to the traditional biomedical content and this purpose.40 then finding and preparing faculty to teach this One hundred years ago, Flexner’s critique of revised curriculum.26-28 medical education converted an evolutionary Reform of the process of clinical education change already under way in North American is even more challenging; however, both regu- medical education into a revolution. Medicine and latory and voluntary efforts are under way.29,30 the sciences underpinning it have made equally Some schools are developing clerkships that no transformative advances since Flexner’s report, longer focus solely on departmental inpatient and once again, our approach to education is in- services but instead include interdisciplinary ap- adequate to meet the needs of medicine. Ossified proaches to the teaching of inpatient and out- curricular structures, a persistent focus on the patient care.31,32 Long-term preceptorships or factual minutiae of today’s knowledge base, dis- apprenticeships are being reestablished to ensure tracted and overcommitted teaching faculty, ar- adequate observation, supervision, and mentor- chaic assessment practices, and regulatory con- ing of trainees. Proposed reforms of residency straints abound. These challenges threaten the education in both medicine and surgery include integrated acquisition of technical knowledge and shortened core rotations and earlier specialty contextual understanding, the appropriately su- training.33-35 But who will do the teaching? Early pervised mastery of practical skills, and the in- experiments to identify, celebrate, and support ternalization of essential values that together a cadre of outstanding clinician-teachers, side by make for an informed, curious, compassionate, side with the laboratory-scientists and physician- proficient, and moral physician. scientists who are academic medicine’s first-class No one would cheer more loudly for a change citizens, hold promise for developing the inno- in medical education than Abraham Flexner. He vative programs and providing the attentive su- recognized that medical education had to recon- pervision, assessment, and mentoring that be- figure itself in response to changing scientific, ginning physicians need.36 social, and economic circumstances in order to A final problem is the financing of medical flourish from one generation to the next. The education.23,37-39 Good teaching, whether it is con- flexibility and freedom to change — indeed, the ducted in the classroom, clinic, or hospital, requires mandate to do so — were part of Flexner’s es- time. Innovative approaches to teaching, progres- sential message. He would undoubtedly support sive skills instruction, multitiered assessment, the fundamental restructuring of medical educa- and support of the development of professional- tion needed today. Indeed, we suspect he would ism all require teachers who have the time to ob- find it long overdue. serve, instruct, coach, and assess their students Supported by the Carnegie Foundation for the Advancement and who also have time for self-reflection and of Teaching and the Atlantic Philanthropies. their own professional development. Although the No potential conflict of interest relevant to this article was reported. educational mission is expensive, many medical We are indebted to Lee Shulman, Ph.D., for his thoughtful con- schools already possess the funds to support teach- tributions. references 1. Training tomorrow’s doctors: the med- ity medical care: a vision for medical edu- 7. Bonner T. Iconoclast: Abraham Flexner ical education mission of academic health cation in the United States. Washington, and a life in learning. Baltimore: Johns centers. New York: The Commonwealth DC: Association of American Medical Hopkins University Press, 2002. Fund, 2002. Colleges, 2004. 8. 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