From Flexner to the Future: Recommendations of the

Carnegie Reports 1910 and 2010

David M. Irby, PhD

NCNMLG/MLGSCA Meeting February 25, 2011

The Carnegie TeamNo financial relationships to disclose

Reforming Medical Education -1910- -2010-

1910: Flexner’s Observations

• Great variability• Lax admissions standards• Passive learning, anemic

curricula, poor facilities• Faculty of practitioners• No accreditation, certification

or residency training

Flexner. Medical Education in the United States and Canada (1910).

Flexner’s Findings in Bay Area

• University of California • Stanford Jr Univ SOM &

Cooper Medical College• College of Physicians &

Surgeons• Hahnemann Med

College of the Pacific• College of Medicine &

Surgery

Flexner’s Recommendations

• High standards for admission – College degree with science

requirements

• Expanded science-based curriculum– Two years basic sciences– Two years clinical experience

• University/teaching hospital

Medical Education Then & Now

-1910- -2010-

2010 Carnegie Study

• Part of 5 profession study• Included 14 site visits• Based on research in the

learning sciences and medical education

*Winner of the 2010 Prose Award for Education from the Association of American Publishers

Recommendations for the Future

• Habits of inquiry and improvement– Focus on excellence

• Integration– Connect knowledge and experience

• Standardization and individualization– Set outcomes and allow flexibility in learning

• Identity formation– Develop professional values and dispositions

Habits of Inquiry & Improvement

• Develop habits of learning and innovation– Develop routine and adaptive

expertise– Achieve information literacy

• Advance expertise through deliberate practice & feedback

• Participate in communities of inquiry and practice

PubMed Articles about Librarians involved in Medical Education

Publication year

Num

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Josephine Tan - UCSF

Josephine Tan - UCSF

Inquiry & Improvement

“How can we improve our transitions of care?”

Everyday Inquiry/Improvement

• Access information, identify best practices and critically appraise the literature

• Engage in QI projects, with training and support

• Document and assess project-based learning

Recommendations for the Future

• Habits of inquiry and improvement– Focus on excellence

• Integration– Connect knowledge and experience

• Standardization and individualization– Set outcomes and allow flexibility in learning

• Identity formation– Develop professional values and dispositions

Integration

• Connect knowledge and experience

• Engage in multiple forms of reasoning– Analytical reasoning – Pattern recognition – Creative and adaptive

reasoning

• Access information and integrate into action

Examples of Integration

• Early clinical immersion

• Longitudinal integrated experience

• Knowledge management and information literacy

Recommendations for the Future

• Habits of inquiry and improvement– Focus on excellence

• Integration– Connect knowledge and experience

• Standardization and individualization– Set outcomes and allow flexibility in learning

• Identity formation– Develop professional values and dispositions

Standardize on Outcomes

• Standardize on learning and practice outcomes

• Develop competencies and milestones

• Use multiple forms of assessment

Competency Frameworks

Competency FrameworksACGME CanMEDS Tomorrow’s

Doctor - UKGood Doctor - Sweden

Medical knowledge

Medical expert Scientist Medical science

Patient care Practitioner

Interpersonal and communication skills

CommunicatorCollaborator

Communication

Practice based learning

Manager

Systems based practice

Health advocate Quality development

Professionalism Professional Professional

Scholar Scholar

Standardization and Milestones

Caverzagie KJ, Aagard EM, Chick DA, Smith CD. Measuring resident progress: Competency milestones in internal medicine. Academic Internal Medicine Insight. 2010;8(1):4-5.

Linear Individualization: Core & Depth

R-3: General Medicine or Subspecialty Focus

R-2: Core + Boards

Additional Subspecialty Training

Additional Subspecialty Training

R-1: Core Internship

Internal MedicineResidency Program

-Depth-

-Core-

Recommendations for the Future

• Habits of inquiry and improvement– Focus on excellence

• Integration– Connect knowledge and experience

• Standardization and individualization– Set outcomes and allow flexibility in learning

• Identity formation– Develop professional values and dispositions

Professional Identity Formation

• Formation– Process of taking on identity – Commitment to values,

dispositions and aspirations

• Learned through – Participation in a community of

practice– Observation of role models,

interactions– Coaching, instruction,

assessment and feedback

Strategies for Formation

• Courses, rituals, and codes of conduct

• Self-assessment, reflection, planning

• Appreciative inquiry

• Ratings of respect

Institutional Culture

Summary

1. Inquire and improve

2. Integrate

3. Individualize and standardize

4. Identity formation

References

• Cooke M, Irby D, Sullivan W, Ludmerer K. American Medical Education One Hundred Years After the Flexner Report. NEJM. 355:1339-1344, 2006.

• Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco: Jossey-Bass, 2010.

• Irby DM, Cooke M, O’Brien B. Calls for Reform of Medical Education by The Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 85(2):220-227, 2010.