Flexner Centenary Professional Formation: Extending Medicine’s Lineage of Service Into the Next Century

In his 1910 report on medical education, Flexner emphasized the importance of competency in basic sciences. Less widely recognized is that he also emphasized the necessity of liberal education. On the Flexner Report’s 100th anniversary, medicine is challenged to realize Flexner’s full vision for medical education to ensure that physicians are prepared to lead lives of compassion and service as well as to perform with technical proficiency. To meet the complex medical and social challenges of the next century, medical educators must continue to promote cognitive expertise while concurrently supporting “professional formation”—the moral and professional development of students, their ability to stay true to their personal service values and the core values of the profession, and the integration of their individual maturation with growth in clinical competency. The goal of professional formation is to anchor students to foundational principles while helping them navigate the inevitable moral conflicts in medical practice. The consequences of inadequate support for professional formation are profound, impacting individual learners, patients, the profession, and society at large. Among the many successful professional formation projects nationally, two long-standing programs are described in modest detail to identify common elements that might guide future developments elsewhere. Key elements include experiential and reflective processes, use of personal narratives, integration of self and expertise, and candid discussion within a safe community of learners. Committing to professional formation within medical education will require transformation of formal and informal curricula and will necessitate a rebalancing of attention and financial support within schools of medicine. Acad Med. 2010; 85:310–317. . . . they had a well-rehearsed habit of holding their own knowledge and beliefs at great remove from the living of their lives. —Parker Palmer, A Hidden Wholeness: The Journey Toward an Undivided Life The publication of Abraham Flexner’s Carnegie Foundation report1 in 1910 is widely recognized to have had a substantial and salutary effect on medical education. Flexner championed a curriculum that integrated laboratory science with experiential learning in clinical environments. This infrastructure still prevails today. Less widely recognized is Flexner’s emphasis on the vital importance of a liberal education in the preparation of physicians.2,3 From his 1910 report: So far we have spoken explicitly of the fundamental sciences only. They furnish, indeed, the essential instrumental basis of medical education. But the instrumental minimum can hardly serve as the permanent professional minimum. It is even instrumentally inadequate.1 Odegaard and Inui2 note that Flexner subsequently regretted that changes in medical education triggered by his report had virtually eliminated a broad education from the medical curriculum and he advocated actively for liberal education in the humanities (including philosophy, ethics, and culture) as a necessary prerequisite for a medical career. Alas, “Flexnerians” in medical education have not heeded his perspective and prescription. On the 100th anniversary of the Flexner Report, we are challenged to reconsider Flexner’s vision of an educational focus broader than the acquisition of cognitive and technical skills in order to ensure that physicians are prepared to lead lives of compassion and service. We now have an opportunity to pick up all the threads of Flexner’s work and reweave into our professional education an emphasis on personal integrity, moral character, and service values. These all have a key role in medical professionalism and competency-based education. A full realization of Flexner’s original vision could not be more timely. Students commonly enter medical school with a well-developed set of service values. Often it is the resonance between their personal values and the lineage values of the profession that attracts students to medicine in the first place. Yet in the last few decades, the operational values of medical practice have become conflicted. With the rapid growth of scientific knowledge and technology, the qualities of predictability, measurability, efficiency, productivity, cost-effectiveness and objectivity have come to assume a priority equal to, if not exceeding, older professional qualities of compassion, avoiding harm, service, altruism, and reverence for life. However, it has become increasingly apparent that biomedical science alone is insufficient to address human illness experiences of suffering, loss, recovery Dr. Rabow is professor, Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California. Dr. Remen is founder and director, Institute for the Study of Health and Illness at Commonweal, and clinical professor, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California. Dr. Parmelee is associate dean for academic affairs and professor, Departments of Psychiatry and Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio. Dr. Inui is president and CEO, Regenstrief Institute, Inc., and Regenstrief Professor of Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana. Correspondence should be addressed to Dr. Rabow, UCSF/Mount Zion, 1701 Divisadero Street #500, San Francisco, CA 94143-1732; telephone: (415) 353-7918; fax: (415) 353-7932; e-mail: [email protected]. Academic Medicine, Vol. 85, No. 2 / February 2010 310 and healing. In fact, biomedicine often intensifies the human agenda— ethical issues become more complex, fair distribution of limited resources becomes more difficult, and the demand for treatment prevails over prevention. The very growth and reach of scientific competence demands an equally powerful development of human understanding and sensitivity. The Flexnerian wisdom has prevailed. Meeting the challenges of the next century will require that medical educators maintain a focus on cognitive and technical expertise while also actively supporting “professional formation”— the moral and professional development of students, the integration of their individual maturation with growth in clinical competency, and their ability to stay true to values which are both personal and core values of the profession. In this paper we will explore the dimensions of professional formation and review the impact of contemporary medical education on student values. We will lay out arguments for the importance of including professional formation in medical education and review the current state of professional formation education in U.S. medical schools. Finally, we will discuss the future of professional formation in medical education and consider its impact on medical educators themselves. Rather than postulating new methods to promote professional formation, our intention in this paper is to review the state of professional formation education in medical schools and highlight successful practices to develop and pursue in the future. Defining Professional Formation Educators have yet to agree on a name for the training designed to support the integrated personal and professional development of learners and have used such terms as “identity formation,” “values education,” or “professionalism training.”4 –7 The analogous process in the training of clergy is called “formation.” In seminaries, formation is understood to encompass the processes intended to prepare an individual to serve a calling. It typically includes: • engaging in service; • reiterating cycles of experience and reflection; • growth in knowledge of self and of the field; and • constant attention to the inner life as well as the life of action. For medical education, we prefer the term “professional formation” because it can be understood to include moral as well as professional development and identity, and it resonates with medicine’s current focus on the skills and commitments of professionalism. The professional formation of medical students and physicians supports the maturation of moral sensibility and the integration of personal values with professional expertise. In discussions, interviews, narratives, and surveys, medical students have affirmed a multitude of values as relevant to their identity and practice as physicians (see List 1). Students learn to prioritize their values on the basis of encounters with normative behavior within the culture of medicine. While some values (such as compassion) are professed explicitly in medical schools, others (such as personal detachment) may conflict with professed values but be absorbed tacitly by learners as normative lessons.8,9 The goal of professional formation is to tether or anchor students to their personal principles and the core values of the profession and help them navigate through the inevitable conflicts that arise in training and practice.10 For example, students holding to the basic principle of the primacy and value of every human life may encounter moral stress when confronted with the need for the allocation of limited resources. A key aspect of professional formation is to offer learners the opportunity to recognize, explore, articulate, prioritize, and share their authentic values and values conflicts within a supportive professional community. Medical educators have the responsibility to help students develop the skills of reflection and critical reasoning to discern the appropriate action amid conflicting personal and professional values. The development of an identity as a physician is the highly personal work of individual students and proceeds in the context of a formal curriculum as well as within a particular learning environment (the informal curriculum).11 Both of these curricula have the potential to support or erode students’ ability to identify and remain committed to foundational personal values and core professional values. Professional formation addresses both these “root value” systems and integrates the values system with which students entered medical school with the contemporary and lineage values of the profession through an ongoing examination of educational and clinical experience.12,13 It has long been recognized that the core values that originally motivate many to enter medical school may be lost or “trained away” during the process of becoming a physician. A number of educators have employed the metaphor of “immunizing” students against the loss of their values, beliefs, and ideals.8 List 1 Values Commonly Identified by Medical Students and Physicians*