An Approaching Shift in Medical Education?

January 30, 2010

This past week we discussed the Flexner Report and its impact on the last century of health care, medical practice and medical education. We also explored how this fit into David’s Charles Handy S-curves of utility of various paradigms in the broader perspective of organizational management. The February issue of Academic Medicine is devoted to a post-Flexner perspective on the future of medical education. From what I’ve seen,this will indeed be complex!

In the abstract to “The Flexnerian Legacy in the 21st Century” in this issue, Darrell Kirch (CEO, Association of American Medical Colleges) states:

At the celebration of the 100th anniversary of the Flexner Report, however, some wonder whether the times require another look at our complex system of medical education. In fact, an underlying theme of many articles in this special issue of Academic Medicine is that the medical education community’s response to the Flexner Report—and the individualistic, expert-centric culture to which it gave rise—may now work against the collaboration needed for greater integration across the medical education continuum, highly networked teams in discovery research, and interprofessionalism in clinical care. The question, as many authors suggest, is not whether medical education is being true to Flexner, but whether academic medicine is responding to the implications of post-Flexnerian education and whether it is able to embrace the cultural change needed to address 21st-century health care needs.

The Carnegie Foundation for the Advancement of Teaching ( was one of the sponsors of the original Flexner Report. Another report is due very shortly, and a preview by Irby, et al,is contained in this issue of Academic Medicine. They envision a medical education system that:

• maximizes flexibility in the process of
achieving standardized outcomes,

• creates opportunities for integrative
and collaborative learning,

• inculcates habits of inquiry and
improvement, and

• provides a supportive learning
environment for the professional
formation of students and residents—
while at the same time it

• advances the health of patients and
patient populations.

These are, for the most part, laudable goals. However, broad generalities are one thing, implementation is quite another. That is the “sticky wicket” (though for the life of me, having read the Laws of Cricket, I still am at a loss as to what a “sticky wicket” actually is! Sorry Dave…) Humphrey, et al, argue that the close association of the medical school with a broader university continues to offer significant advantages towards the above ends. Miller, et al, from Vanderbilt, have formulated the following Principles for Health Workforce Development:

Principles of the New Model for Health Workforce Development*

1. Learning is competency-based and embedded in the workplace.

2. All workers learn; all learners work.

3. Learning is undertaken by individuals, teams, and institutions and is linked to patient needs.

4. Learning activities are modular; the system allows multiple entry and exit points.

5. Learning is inter-professional, with shared facilities, common schedules, and shared foundational coursework.

6. A rich information technology infrastructure supports the healthcare/learning system.

7. Health outcomes and educational outcomes are directly linked.

On balance, I think this portends a positive shift in medical education, which should translate into a positive shift on the whole of medical care and thus health care. I am still concerned about a few things, though. In David’s description of paradigm/utility, the middle curve, a “systems approach”, centers on “mass customization”. I think the emphasis on standardized outcomes and individualized process may prove to be too limiting. Likewise, the concentration on competence and virtual ignoring of capability continues to look backward, not forward. Is this just semantics? I am not sure. I think I see a glimmer of understanding that the organizational culture needs to be addressed (see Tribal Leadership post), but there is still a lot of “I’m Great and You’re Not” that needs to be addressed in order to move to the next level.

Nevertheless, we are moving in the right direction. My own perspective is that third curve in David’s scenario, the “Sense-Making” with its ability to situate a network, mass collaboration, social computing and globalization. Education must move towards this paradigm in order to make the same quantum leap that the Flexner Report made possible 100 years ago. While the medical school as part of a university may be a venue to make this happen, other avenues may be better situated to make this leap. A medical school has an individual for 4 years, or perhaps even up to 10 if advanced training is done in the same institution. An integrated health network has the individual for 30 or 40 years. For the complex problems that face the current health care workers, the ideal venue may be such a network, with strong affiliations with a medical school, nursing school, pharmacy school and school of public health. The kind of distributed cognition needed for emergence of the types of health care appropriate for any given starting point can not be relegated to “experts”. The experts need to transform themselves into facilitators. Ironically, this is perhaps what Abraham Flexner originally envisioned in his model of a medical faculty that concentrated on teaching first and clinical care revenue production second. The more I think about it, Flexner is more complex than I originally thought!

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