Working Toward a Philosophy of Medical Education Transformation
Adina Kalet, MD, MPH
The education of healers has always mattered to society. Over the centuries following Hippocrates, physicians received training as apprentices, each learning from a mentor and practicing precepts handed down in centuries-old texts. By the end of the 1800s, the U.S. was dotted with various types and qualities of medical schools and medical “sects.” No license was needed. Anyone could “practice medicine” in the U.S. Unstudied treatments were often toxic or deadly.
In 1910, Abraham Flexner, an American educational transformer supported by the Carnegie Foundation, released a report outlining how medical education should be structured, including periods of preclinical and clinical content with standardized, significant, supervised learning centered around the role of science. The report forced the closure or consolidation of almost half of US medical schools, improving the quality of medical education and practice across the US, but also effectively limiting training to upper class men and limiting high-quality healthcare access to those who could afford to pay. These are consequences we have yet to fully overcome.
Medical School Transformation Usually Focuses on the “How” Rather Than the “Why”
Because medical education is so vital, there have been constant efforts at transformation. Since Flexner, though, much of the “reform” has focused on the how of education rather than the why. For example, curricular reform has focused on content elements, reallocation of contact hours for curriculum, various instructional approaches and techniques (e.g. Problem Based Learning and OSCEs), and implementation strategies. There have been winners and losers, but by engaging in curricular reform without articulating the bigger ideas or respecting the social forces afoot, medical schools and their faculties are traumatized. Real transformation has not been accomplished; real paradigm shifts have yet to occur.
So, if we want to truly transform medical education, we must strike at the why. How will we decide when to heed the calls to make changes? What ideas and principles should guide the reforms? Who gets to make these decisions? How much consensus is needed before we act? When is it right or no longer defensible to keep things as they are? What is the purpose of medical education anyway? These are philosophical questions not technical ones.
Philosophy, Practical Wisdom, and a Focus on the “Why”
Philosophy (literally, “the love of wisdom”) is a way of thinking. It asks basic, general, probing questions about the nature of human thought, the universe, and the connections between them. It provides a lens to analyze complex situations and, therefore, a method to make good (i.e., moral and virtuous) decisions. Philosophy articulates the deeper thinking that underlies visible actions. It is a “superset of principles” that explores how to think, not what to think. It does not provide answers, but it does shape our decision making. For instance, how would such an approach guide our work if we acted as if medical education needs to prioritize people and learning, not structures? How would we change the structure of medical school curriculum?
In the Kern Institute, just as we explore creativity, innovation, cutting-edge faculty development, instructional design, and pedagogy, we are – at the same time – articulating a philosophy of medical education transformation. Four Kern faculty members are trained philosophers: Arthur Derse, MD, JD, Ryan Spellecy, PhD, Christopher Stawski, PhD, and Fabrice Jotterand, PhD, who bring together extensive experience in biomedical and research ethics, philosophy of medicine, humanities, clinical practice, community health, sociology, and character education. As part of the Institute’s Practical Wisdom Group, they meet regularly to explore how the Kern Institute’s values of character, caring and competence should guide transformation of medical education. A model is emerging.
As the Kern Institute’s resident philosopher, Fabrice Jotterand, PhD, will work with MCW faculty members, MCW students, and a group of international scholars to deepen the dialogue so we can articulate our philosophy of medical education. This kind of work is difficult. It takes time, a precious commodity for pragmatic, busy physicians and scientists. However, taking this time is critical and a great privilege in the modern world of medicine. The stakes are high.
Moving Beyond the Flexner Report
At the one hundred-year anniversary of the Flexner Report in 2010, a rigorous Carnegie Foundation study of American medical education by Cooke, Irby, and O’Brien made dramatic recommendations for changes in the medical school curriculum. These included:
- Standardizing learning outcomes and individualizing the learning process
- Promoting multiple forms of integration of basic medical and clinical sciences
- Incorporating habits of inquiry and improvement
- Focusing on the progressive formation of the physician's professional identity
These recommendations, if implemented, will enable us to move away from dictating the length of time each student spends in an educational program – the “dwell time” – and move toward an emphasis on accomplishing the needed learning, a pedagogical philosophy known as “competency-based, time variable medical education.” This, along with an unprecedented increase since 2002 in the opening of new US medical schools and regional campuses, would expand access to both the profession and to medical care, offering opportunities to articulate and act on medicine’s commitment to address societal needs as part of medical education transformation.
As an ancient profession, medicine finds itself in tension between holding firm to grand traditions versus embracing new ideas, social change, and cutting- edge pedagogy. There is no one best way to educate physicians but there are better and worse ways. As we deepen our understanding of how to address the big questions, we will need the courage to pursue the answers we uncover.
Ref: Irby DM, Cooke M, O’Brien BC, Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine. 2010 Feb;85(2):220-7. doi: 10.1097/ACM.0b013e3181c88449.
Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.
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