Review Article
Medical Education
Malcolm Cox, M.D., Editor, David M. Irby, Ph.D., Editor
American Medical Education 100 Years after the Flexner Report
N Engl J Med 2006; 355:1339-1344September 28, 2006
- Article
Medical education seems to be in a perpetual state of unrest. From the early 1900s to the present, more than a score of reports from foundations, educational bodies, and professional task forces have criticized medical education for emphasizing scientific knowledge over biologic understanding, clinical reasoning, practical skill, and the development of character, compassion, 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, we summarize the changes in medical education over the past century and describe 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 Foundation 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 right; it was important because it led to better patient care and teaching. Indeed, he subscribed to the motto, “Think much; publish little.”9
Transformation of Medicine in the 20th Century
The academic environment has been transformed since Flexner's day. In academic hospitals, research quickly outstripped teaching in importance, and a “publish or perish” culture emerged in American universities and medical schools. Research productivity became the metric by which faculty accomplishment was judged; teaching, caring for patients, and addressing broader public health issues were viewed as less important activities. Thus, today's subordination of teaching to research, as well as the narrow gaze of American medical education on biologic matters, represents a long-standing tradition.8
In addition to the shift in the importance of research relative to teaching and patient care, a transformation in the process of research on human disease has contributed to our current state of affairs. For the first half of the 20th century, a distinctive feature of American medical education was the integration of investigation with teaching and patient care. Teaching, clinical care, and investigation each served the others' purposes, 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 increase their clinical productivity — that is, to generate revenues by providing care for paying patients.11-13 As a result, they have less time available for teaching, often to their immense frustration. In addition, the harsh, commercial atmosphere of the marketplace has permeated many academic medical centers. Students hear institutional leaders speaking more about “throughput,” “capture of market share,” “units of service,” and the financial “bottom line” than about the prevention and relief of suffering. Students learn from this culture that health care as a business may threaten medicine as a calling.
Thus we arrive at our current predicament: medical students and residents are often taught clinical medicine either by faculty who spend very limited time seeing patients and honing their clinical skills (and who regard the practice of medicine as a secondary activity in their careers) or by teachers who have little familiarity with modern biomedical science (and who see few, if any, academic rewards in leaving their busy practices to teach). In either case, many clinical teachers no longer exemplify Flexner's model of the clinician-investigator.
Learning Medicine as Professional Education
All forms of professional education share the goal of readying students for accomplished and responsible practice in service to others. Thus, professionals in training must master both abundant theory and large bodies of knowledge; the final test of their efforts, however, will be not what they know but what they do. The purpose of medical education is to transmit the knowledge, impart the skills, and inculcate the values of the profession in an appropriately balanced and integrated manner.14,15 In the apprenticeship model of medical training that prevailed into the mid-19th century, student physicians encountered this knowledge and these skills and values as enacted by their teachers in the course of caring for patients. How are knowledge, skills, and professional values represented in contemporary medical education?
The way in which students encounter the knowledge base of medicine has been profoundly influenced, as Flexner intended, by the assimilation of medical education into the culture of the university. Theoretical, scientific knowledge formulated in context-free and value-neutral terms is seen as the primary basis for medical knowledge and reasoning. This knowledge is grounded in the basic sciences; the academy accommodates less comfortably the practical skills and distinct moral orientation required for successful practice in medicine. However, Flexner had not intended that such knowledge should be the sole or even the predominant basis for clinical decision making.5 Within 15 years after issuing his report, Flexner had come to believe that the medical curriculum overweighted the scientific aspects of medicine to the exclusion of the social and humanistic aspects. He wrote in 1925, “Scientific medicine in America — young, vigorous and positivistic — is today sadly deficient in cultural and philosophic background.”16 He undoubtedly would be disappointed to see the extent to which this critique still holds true.
Responsibility for the care of patients is a powerful stimulus for learning,17 and active learning requires that clinical skills, both cognitive and procedural, be attained through the supervised provision of patient care. As Flexner recognized, medical novices require the opportunity to practice skills under the guidance of experienced teaching physicians until they attain a high level of proficiency. Increasing attention to the quality of care, patient safety, and documentation of care enhances medical practice18 but threatens to relegate trainees to the role of passive observer. Given that every patient deserves the best possible care, we are challenged to provide appropriate opportunities for experiential learning and practice while meeting the service demands of teaching hospitals. The educational mission of teaching hospitals is further compromised by the absence of performance standards and assessment methods that can clearly establish that learners are ready to advance to the next level of independence and challenge.
The moral dimension of medical education requires that students and residents acquire a crucial set of professional values and qualities, at the heart of which is the willingness to put the needs of the patient first. A generation ago, the hours worked served as a simple proxy for dedication to patients; now, an appropriate concern for the well-being of trainees and the safety of their patients demands a new understanding of what it means to be dedicated to one's patients.19 Professional values are continuously exemplified and enacted in the course of medical education through role modeling, setting expectations, telling stories and parables, and interacting with the health care environment, not just in courses on ethics and patient–doctor communication. However, the values of the profession are becoming increasingly difficult for learners to discern; the conclusions they draw, as they witness the struggle of underinsured working people to obtain health care, marked differences in the use of expensive technologies in different health care environments, and their physician-teachers in complicated relationships with companies that make health care products, should concern us.
Not only has the knowledge base for medical practice hypertrophied since Flexner's day, but the delivery of care has also become vastly more complicated, and the expectations of the public higher. However, it has been difficult to integrate the new skills, knowledge, and attitudes required for proficient practice into medical education at both the predoctoral and residency levels. Although many students and residents are interested in learning about interprofessional teamwork, population health, and health policy and the organization of health services, these topics tend to be poorly represented in medical school and residency curricula. It can be hard to teach messy real-world issues, but practitioners need to understand how these issues affect their patients and how to interact with, and ultimately improve, an exceedingly complex and fragmented system to provide good patient care.
Preparing Physicians for the 21st Century
What can be done to bring the knowledge, skills, and values that must be imparted by medical education into better balance and to prepare outstanding physicians for the 21st century? As the articles in this series will illustrate, the solutions are apparent for some problems, but medical schools and the institutions that sponsor residency programs need to develop the will to implement them. Other problems are more complex, and their solutions more uncertain. With respect to medical knowledge, the gaps between what we know about how people learn and how medicine is currently taught can be corrected. Cognitive psychology has demonstrated that facts and concepts are best recalled and put into service when they are taught, practiced, and assessed in the context in which they will be used.20 Several decades of research on clinical expertise have elucidated the thinking of physicians as they evaluate signs and symptoms, select and interpret diagnostic tests, and synthesize data to develop clinical assessments and care plans; these insights can be shared with learners as well as their teachers.21
The acquisition of skills for practice requires radical transformation. Although the dictum “see one, do one, teach one” may have characterized the way in which clinical skills were learned in the past, it is now clear that for training in skills to be effective, learners at all levels must have the opportunity to compare their performance with a standard and to practice until an acceptable level of proficiency is attained. An appreciation of the importance of practice and the honest admission that neophytes cannot perform high-stakes procedures at an acceptable level of proficiency demand that we develop approaches to skills training that do not put our patients at risk in service to education. The use of increasingly sophisticated simulations and virtual reality offers physicians at all levels the opportunity to refresh skills and learn new ones in a safe practice environment. Educational methods that allow the demonstration of mastery at one level, with respect to both technique and judgment, before progression to the next level teach an important lesson in professionalism as well.
The groundwork that has been laid by explicit instruction in professionalism, combined with effective role modeling and attention to the hidden curriculum of the practice environment, can support the development of a comprehensive and sophisticated understanding of professional education.22 Sociologists have noted the importance of socialization and implicit learning in the development of professional attitudes and behaviors.23
It has long been observed that assessment drives learning. If we care whether medical students and residents become skillful practitioners and sensitive and compassionate healers, as well as knowledgeable technicians, our approaches to the evaluation of learners must reach beyond knowledge to rigorously assess procedural skills, judgment, and commitment to patients. Self-assessment, peer evaluations, portfolios of the learner's work, written assessments of clinical reasoning, standardized patient examinations, oral examinations, and sophisticated simulations are used increasingly to support the acquisition of appropriate professional values as well as knowledge, reasoning, and skills. Rigorous assessment has the potential to inspire learning, influence values, reinforce competence, and reassure the public.24
Much of what we know about effective interventions is not translated from research settings into everyday patient care. Increasing emphasis is being placed on evidence-based practice, systems approaches, and quality improvement. Advances in these areas require the ability to integrate scientific discoveries and context-specific experimentation for the continuous improvement of the processes of medical practice. New paradigms that connect these processes are emerging, and they have the potential to revolutionize both the way in which people learn and the environment in which learning takes place.25
Finding the Will to Change
The need for a fundamental redesign of the content of medical training is clear. In some instances, the road that needs to be taken is also clear — for example, more emphasis should be placed on the social, economic, and political aspects of health care delivery. However, curricular reform is never simple or easy, and “turf battles” are inevitable. The challenge is not defining the appropriate content but rather incorporating it into the curriculum in a manner that emphasizes its importance relative to the traditional biomedical content and then finding and preparing faculty to teach this revised curriculum.26-28
Reform of the process of clinical education is even more challenging; however, both regulatory and voluntary efforts are under way.29,30 Some schools are developing clerkships that no longer focus solely on departmental inpatient services but instead include interdisciplinary approaches to the teaching of inpatient and outpatient care.31,32 Long-term preceptorships or apprenticeships are being reestablished to ensure adequate observation, supervision, and mentoring of trainees. Proposed reforms of residency education in both medicine and surgery include shortened core rotations and earlier specialty training.33-35 But who will do the teaching? Early experiments to identify, celebrate, and support a cadre of outstanding clinician-teachers, side by side with the laboratory-scientists and physician-scientists who are academic medicine's first-class citizens, hold promise for developing the innovative programs and providing the attentive supervision, assessment, and mentoring that beginning physicians need.36
A final problem is the financing of medical education.23,37-39 Good teaching, whether it is conducted in the classroom, clinic, or hospital, requires time. Innovative approaches to teaching, progressive skills instruction, multitiered assessment, and support of the development of professionalism all require teachers who have the time to observe, instruct, coach, and assess their students and who also have time for self-reflection and their own professional development. Although the educational mission is expensive, many medical schools already possess the funds to support teaching properly, if they choose to use the funds for this purpose.40
One hundred years ago, Flexner's critique of medical education converted an evolutionary change already under way in North American medical education into a revolution. Medicine and the sciences underpinning it have made equally transformative advances since Flexner's report, and once again, our approach to education is inadequate to meet the needs of medicine. Ossified curricular structures, a persistent focus on the factual minutiae of today's knowledge base, distracted and overcommitted teaching faculty, archaic assessment practices, and regulatory constraints abound. These challenges threaten the integrated acquisition of technical knowledge and contextual understanding, the appropriately supervised mastery of practical skills, and the internalization of essential values that together make for an informed, curious, compassionate, proficient, and moral physician.
No one would cheer more loudly for a change in medical education than Abraham Flexner. He recognized that medical education had to reconfigure itself in response to changing scientific, social, and economic circumstances in order to flourish from one generation to the next. The flexibility and freedom to change — indeed, the mandate to do so — were part of Flexner's essential message. He would undoubtedly support the fundamental restructuring of medical education needed today. Indeed, we suspect he would find it long overdue.
Supported by the Carnegie Foundation for the Advancement of Teaching and the Atlantic Philanthropies.
No potential conflict of interest relevant to this article was reported.
We are indebted to Lee Shulman, Ph.D., for his thoughtful contributions.
Source Information
From the Department of Medicine, University of California, San Francisco, San Francisco (M.C., D.M.I.); the Carnegie Foundation for the Advancement of Teaching, Stanford, CA (M.C., D.M.I., W.S.); and the Department of Medicine, Washington University, St. Louis (K.M.L.).
- References
References
1
Training tomorrow's doctors: the medical education mission of academic health centers. New York: The Commonwealth Fund, 2002.
2
The Blue Ridge Academic Health Group. Reforming medical education: urgent priority for academic health center in the new century. Atlanta: Robert W. Woodruff Health Sciences Center, 2003.
3
Committee on the Roles of Academic Health Centers in the 21st Century. Academic health centers: leading change in the 21st century. Washington, DC: Institute of Medicine, 2003.
4
Educating doctors to provide high quality medical care: a vision for medical education in the United States. Washington, DC: Association of American Medical Colleges, 2004.
5
Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching. New York: Carnegie Foundation for the Advancement of Teaching, 1910.
6
Lagemann E. Private power for the public good: a history of the Carnegie Foundation for the Advancement of Teaching. Middletown, CT: Wesleyan University Press, 1983.
7
Bonner T. Iconoclast: Abraham Flexner and a life in learning. Baltimore: Johns Hopkins University Press, 2002.
8
Ludmerer K. Learning to heal: the development of American medical education. New York: Basic Books, 1985.
9
Flexner A. I remember: the autobiography of Abraham Flexner. New York: Simon and Schuster, 1940.
10
Ludmerer K . The internal challenges to medical education. Trans Am Clin Climatol Assoc 2003;114:241-253
Medline11
Tarquinio GT ,Dittus RS ,Byrne DW ,Kaiser A ,Neilson EG . Effects of performance-based compensation and faculty track on the clinical activity, research portfolio, and teaching mission of a large academic department of medicine. Acad Med 2003;78:690-701
CrossRef | Web of Science | Medline12
Williams RG ,Dunnington GL ,Folse JR . The impact of a program for systematically recognizing and rewarding academic performance. Acad Med 2003;78:156-166
CrossRef | Web of Science | Medline13
Berger TJ ,Ander DS ,Terrell ML ,Berle DC . The impact of the demand for clinical productivity on student teaching in academic emergency departments. Acad Emerg Med 2004;11:1364-1367
CrossRef | Web of Science | Medline14
Sullivan W. Work and integrity: the crisis and promise of professionalism in America. 2nd ed. San Francisco: Jossey-Bass, 2005.
15
Collins A, Brown J, Newman S. Cognitive apprenticeship: teaching the crafts of reading, writing and mathematics. In: Resnick L, ed. Knowing, learning and instruction: essays in honor of Robert Glaser. Hillsdale, NJ: Lawrence Erlbaum Associates, 1989:453-94.
16
Flexner A. Medical education: a comparative study. New York: MacMillan, 1925.
17
Miller J ,Bligh J ,Stanley I ,al Shehri A . Motivation and continuation of professional development. Br J Gen Pract 1998;48:1429-1432
Web of Science | Medline18
Turning research into practice: cases on adopting evidence-based innovations for everyday care. Qual Lett Healthc Lead 2004;16:2-3, 5
19
Van Eaton EG ,Horvath KD ,Pellegrini CA . Professionalism and the shift mentality: how to reconcile patient ownership with limited work hours. Arch Surg 2005;140:230-235
CrossRef | Web of Science | Medline20
Bransford J, Brown A, Cocking R. How people learn: brain, mind, experience, and school. Washington, DC: National Academy Press, 1999.
21
Norman G . Research in clinical reasoning: past history and current trends. Med Educ 2005;39:418-427
CrossRef | Web of Science | Medline22
Cruess RL ,Cruess SR . Teaching medicine as a profession in the service of healing. Acad Med 1997;72:941-952
CrossRef | Web of Science | Medline23
Sinclair S. Making doctors: an institutional apprenticeship. Oxford, England: Berg, 1997.
24
Epstein RM ,Hundert EM . Defining and assessing professional competence. JAMA 2002;287:226-235
CrossRef | Web of Science | Medline25
Berwick D. Escape fire: designs for the future of health care. San Francisco: Jossey-Bass, 2004.
26
Mennin SP ,Kalishman S . Issues and strategies for reform in medical education: lessons from eight medical schools. Acad Med 1998;73:Suppl:S1-S64
CrossRef | Web of Science | Medline27
Davis AK ,Kahn NB ,Wartmann SA ,Wilson M ,Kahn R . Lessons from the Interdisciplinary Generalist Curriculum Project. Acad Med 2001;76:Suppl:S1-S157
CrossRef | Web of Science28
Pascoe JM ,Cox M ,Lewin LO ,Weiss MD ,Pye KL . Report on undergraduate medical education for the 21st century (UME-21): a national medical education project. Fam Med 2004;36:Suppl:S2-S15029
Leach DC . A model for GME: shifting from process to outcomes -- a progress report from the Accreditation Council for Graduate Medical Education. Med Educ 2004;38:12-14
CrossRef | Web of Science | Medline30
Whitcomb ME . Redesigning clinical education: a major challenge for academic health centers. Acad Med 2005;80:615-616
CrossRef | Web of Science | Medline31
Speer AJ ,Stagnaro-Green A ,Elnicki DM . Interdisciplinary clerkships: educational models of the future? Am J Med 1995;99:451-453
CrossRef | Web of Science | Medline32
Harden R ,Crosby J ,Davis MH ,Howie PW ,Struthers AD . Task-based learning: the answer to integration and problem-based learning in the clinical years. Med Educ 2000;34:391-397
CrossRef | Web of Science | Medline33
DaRosa DA ,Bell RH Jr ,Dunnington GL . Residency program models, implications, and evaluation: results of a think tank consortium on resident work hours. Surgery 2003;133:13-23
CrossRef | Web of Science | Medline34
Goldman L . Modernizing the paths to certification in internal medicine and its subspecialties. Am J Med 2004;117:133-136
CrossRef | Web of Science | Medline35
Pellegrini CA ,Warshaw AL ,Debas HT . Residency training in surgery in the 21st century: a new paradigm. Surgery 2004;136:953-965
CrossRef | Web of Science | Medline36
Dewey CM ,Friedland JA ,Richards BF ,Lamki N ,Kirkland RT . The emergence of academies of educational excellence: a survey of U.S. medical schools. Acad Med 2005;80:358-365
CrossRef | Web of Science | Medline37
Knapp R . Financing graduate medical education and limiting resident work hours: a political assessment. Am J Surg 2002;184:187-195
CrossRef | Web of Science | Medline38
Knapp RM . Complexity and uncertainty in financing graduate medical education. Acad Med 2002;77:1076-1083
CrossRef | Web of Science | Medline39
Reinhardt UE . Academic medicine's financial accountability and responsibility. JAMA 2000;284:1136-1138
CrossRef | Web of Science | Medline40
Ludmerer KM . Learner-centered medical education. N Engl J Med 2004;351:1163-1164
Full Text | Web of Science | Medline
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T. M. Wilkinson. (2010) Medical reasoning and the failure of electronic medical record systems in the United States. International Journal of Clinical Practice 64:7, 839-842
CrossRef47
Christopher S. Sales, Anthony L. Schlaff. (2010) Reforming medical education: A review and synthesis of five critiques of medical practice. Social Science & Medicine 70:11, 1665-1668
CrossRef48
Niklas Wilhelmsson, Lars Owe Dahlgren, Håkan Hult, Max Scheja, Kirsti Lonka, Anna Josephson. (2010) The anatomy of learning anatomy. Advances in Health Sciences Education 15:2, 153-165
CrossRef49
David M. Fetterman, Jennifer Deitz, Neil Gesundheit. (2010) Empowerment Evaluation: A Collaborative Approach to Evaluating and Transforming a Medical School Curriculum. Academic Medicine 85:5, 813-820
CrossRef50
Manuel Pardo. (2010) Anesthesia: How to Organize and Train Our Teachers. Anesthesiology 112:4, 773-774
CrossRef51
Roger A. Rosenblatt. (2010) Commentary: Do Medical Schools Have a Responsibility to Train Physicians to Meet the Needs of the Public? The Case of Persistent Rural Physician Shortages. Academic Medicine 85:4, 572-574
CrossRef52
Nathan G. Congdon, Tin Aung. (2010) A Tale of Two Systems: Health Reform in China and the United States. Ophthalmology 117:3, 407-408
CrossRef53
Charles M. Wiener, Patricia A. Thomas, Elizabeth Goodspeed, David Valle, David G. Nichols. (2010) “Genes to Society”—The Logic and Process of the New Curriculum for the Johns Hopkins University School of Medicine. Academic Medicine 85:3, 498-506
CrossRef54
Michael W. Rabow, Rachel N. Remen, Dean X. Parmelee, Thomas S. Inui. (2010) Professional Formation: Extending Medicineʼs Lineage of Service Into the Next Century. Academic Medicine 85:2, 310-317
CrossRef55
Frederic W. Hafferty, Brian Castellani. (2010) The Increasing Complexities of Professionalism. Academic Medicine 85:2, 288-301
CrossRef56
Zubair Amin, William P. Burdick, Avinash Supe, Tejinder Singh. (2010) Relevance of the Flexner Report to Contemporary Medical Education in South Asia. Academic Medicine 85:2, 333-339
CrossRef57
J Donald Boudreau, Eric J. Cassell. (2010) Abraham Flexnerʼs “Mooted Question” and the Story of Integration. Academic Medicine 85:2, 378-383
CrossRef58
Michael D. Prislin, John W. Saultz, John P. Geyman. (2010) The Generalist Disciplines in American Medicine One Hundred Years Following the Flexner Report: A Case Study of Unintended Consequences and Some Proposals for Post-Flexnerian Reform. Academic Medicine 85:2, 228-235
CrossRef59
David M. Irby, Molly Cooke, Bridget C. OʼBrien. (2010) Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine 85:2, 220-227
CrossRef60
T Samuel Shomaker. (2010) For-Profit Undergraduate Medical Education: Back to the Future?. Academic Medicine 85:2, 363-369
CrossRef61
David J. Doukas, Laurence B. McCullough, Stephen Wear. (2010) Reforming Medical Education in Ethics and Humanities by Finding Common Ground With Abraham Flexner. Academic Medicine 85:2, 318-323
CrossRef62
David R. Lambert, Stephen J. Lurie, Jeffrey M. Lyness, Denham S. Ward. (2010) Standardizing and Personalizing Science in Medical Education. Academic Medicine 85:2, 356-362
CrossRef63
Raymond H. Curry, Kathryn Montgomery. (2010) Toward a Liberal Education in Medicine. Academic Medicine 85:2, 283-287
CrossRef64
Susan E. Skochelak. (2010) Commentary: A Century of Progress in Medical Education: What About the Next 10 Years?. Academic Medicine 85:2, 197-200
CrossRef65
Stewart Mennin. (2010) Self-organisation, integration and curriculum in the complex world of medical education. Medical Education 44:1, 20-30
CrossRef66
(2010) Reports of PhD studies selected for presentation at the AMEE 2009 conference in Malaga, Spain, 29 August to 2 September. Medical Teacher 32:4, 319-326
CrossRef67
Marja G K Dijksterhuis, Marlies Voorhuis, Pim W Teunissen, Lambert W T Schuwirth, Olle T J ten Cate, Didi D M Braat, Fedde Scheele. (2009) Assessment of competence and progressive independence in postgraduate clinical training. Medical Education 43:12, 1156-1165
CrossRef68
John L. Tarpley, Margaret J. Tarpley. (2009) Presidential address: what business are we in?. The American Journal of Surgery 198:5, 583-587
CrossRef69
Ruth-Marie E. Fincher, Paul M. Wallach, W. Scott Richardson. (2009) Basic Science Right, Not Basic Science Lite: Medical Education at a Crossroad. Journal of General Internal Medicine 24:11, 1255-1258
CrossRef70
Eric P. Brass. (2009) Basic Biomedical Sciences and the Future of Medical Education: Implications for Internal Medicine. Journal of General Internal Medicine 24:11, 1251-1254
CrossRef71
Timothy F Brewer, Nicole Saba, Veronic Clair. (2009) From boutique to basic: a call for standardised medical education in global health. Medical Education 43:10, 930-933
CrossRef72
Sevgi Turan, Melih Elcin, Sarp Uner, Orhan Odabasi, Iskender Sayek, Nuray Senemoglu. (2009) The impact of clinical visits on communication skills training. Patient Education and Counseling 77:1, 42-47
CrossRef73
Kitt Shaffer, Joshua M. Ng, David A. Hirsh. (2009) An Integrated Model for Radiology Education. Academic Radiology 16:10, 1292-1301
CrossRef74
T. L. Cascino, D. A. Cortese. (2009) Preparing Professionals to Serve in a Reformed Health Care System. Mayo Clinic Proceedings 84:10, 862-863
CrossRef75
Julie Ash. (2009) Understanding clinical teaching in times of change. The Clinical Teacher 6:3, 177-180
CrossRef76
Sonia J. Crandall, Gail S. Marion. (2009) Commentary: Identifying Attitudes Towards Empathy: An Essential Feature of Professionalism. Academic Medicine 84:9, 1174-1176
CrossRef77
Maria A Wamsley, Nadine Dubowitz, Puja Kohli, Molly Cooke, Bridget C O’Brien. (2009) Continuity in a longitudinal out-patient attachment for Year 3 medical students. Medical Education 43:9, 895-906
CrossRef78
Molly Blackley Jackson, Misbah Keen, Marjorie D. Wenrich, Doug C. Schaad, Lynne Robins, Erika A. Goldstein. (2009) Impact of a Pre-Clinical Clinical Skills Curriculum on Student Performance in Third-Year Clerkships. Journal of General Internal Medicine 24:8, 929-933
CrossRef79
Andrea Wershof Schwartz, Jeremy S. Abramson, Israel Wojnowich, Robert Accordino, Edward J. Ronan, Mary R. Rifkin. (2009) Evaluating the Impact of the Humanities in Medical Education. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine 76:4, 372-380
CrossRef80
Lee Ann Riesenberg, Brian W. Little, Vaughn Wright. (2009) Nonphysician Medical Educators: A Literature Review and Job Description Resource. Academic Medicine 84:8, 1078-1088
CrossRef81
Lisa Coplit. (2009) Innovations in Medical Education: Getting Closer to Our Goals. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine 76:4, 315-317
CrossRef82
Garabed Eknoyan. (2009) The Wonderful Apparatus of John Jacob Abel Called the “Artificial Kidney”. Seminars in Dialysis 22:3, 287-296
CrossRef83
Bin Zheng, Michelle D. Taylor, Lee L. Swanström. (2009) An observational study of surgery-related activities between nurses and surgeons during laparoscopic surgery. The American Journal of Surgery 197:4, 497-502
CrossRef84
J.M. García Santos. (2009) ¿Quién es autor?. Radiología 51:1, 3-5
CrossRef85
(2009) How to throw the baby out with the bath water. Internal Medicine Journal 39:2, 75-76
CrossRef86
Vimla L. Patel, Nicole A. Yoskowitz, Jose F. Arocha, Edward H. Shortliffe. (2009) Cognitive and learning sciences in biomedical and health instructional design: A review with lessons for biomedical informatics education. Journal of Biomedical Informatics 42:1, 176-197
CrossRef87
M.E. Beth Smith, Sima S. Desai, Elizabeth S. Allen, Somnath Saha, Alan J. Hunter. (2009) Impact of Shorter Inpatient Faculty Rotations on Resident Learning Experience. The American Journal of Medicine 122:1, 96-100
CrossRef88
Michelle Farrar, Anne M Connolly, John Lawson, Annette Burgess, Amy Lonergan, Ann M E Bye. (2008) Teaching doctors how to diagnose paroxysmal events: a comparison of two educational methods. Medical Education 42:9, 909-914
CrossRef89
Therese Zink, Gwen W. Halaas, Deborah Finstad, Kathleen D. Brooks. (2008) The Rural Physician Associate Program: The Value of Immersion Learning for Third-Year Medical Students. The Journal of Rural Health 24:4, 353-359
CrossRef90
Jessica H Muller, Sharad Jain, Helen Loeser, David M Irby. (2008) Lessons learned about integrating a medical school curriculum: perceptions of students, faculty and curriculum leaders. Medical Education 42:8, 778-785
CrossRef91
Italo Vantini, Luigi Benini. (2008) Models of learning, training and progress evaluation of medical students. Clinica Chimica Acta 393:1, 13-16
CrossRef92
Gary Sutkin, Elizabeth Wagner, Ilene Harris, Randolph Schiffer. (2008) What Makes a Good Clinical Teacher in Medicine? A Review of the Literature. Academic Medicine 83:5, 452-466
CrossRef93
Sigall K. Bell, Edward Krupat, Sara B. Fazio, David H. Roberts, Richard M. Schwartzstein. (2008) Longitudinal Pedagogy: A Successful Response to the Fragmentation of the Third-Year Medical Student Clerkship Experience. Academic Medicine 83:5, 467-475
CrossRef94
Kent Hecker, Claudio Violato. (2008) How Much Do Differences in Medical Schools Influence Student Performance? A Longitudinal Study Employing Hierarchical Linear Modeling. Teaching and Learning in Medicine 20:2, 104-113
CrossRef95
Melinda Lyons. (2008) Do classical origins of medical terms endanger patients?. The Lancet 371:9621, 1321-1322
CrossRef96
M. R. Mercurio. (2008) An Analysis of Candidate Ethical Justifications for Allowing Inexperienced Physicians-in-Training to Perform Invasive Procedures. Journal of Medicine and Philosophy 33:1, 44-57
CrossRef97
Michael B. Cohen. (2008) Pathology and the humanities. Human Pathology 39:1, 1-2
CrossRef98
Michelle McLean, Francois Cilliers, Jacqueline M. Van Wyk. (2008) Faculty development: Yesterday, today and tomorrow. Medical Teacher 30:6, 555-584
CrossRef99
Rita Sood. (2008) Medical education in India. Medical Teacher 30:6, 585-591
CrossRef100
Carrie J. Petrucci, Kathleen M. Quinlan. (2007) Bridging the Research-Practice Gap. Journal of Social Service Research 34:2, 25-42
CrossRef101
Richard B. Gunderman, Michael Bettmann, Lawrence P. Davis. (2007) Promoting Educational Innovation: Lessons From the Request for Proposals for ACR Appropriateness Criteria® Usage in Medical Education. Journal of the American College of Radiology 4:12, 919-924
CrossRef102
Andrew H. Brainard, Heather C. Brislen. (2007) Viewpoint: Learning Professionalism: A View from the Trenches. Academic Medicine 82:11, 1010-1014
CrossRef103
Kirk L. Smith, Rebecca Saavedra, Jennifer L. Raeke, Alice Anne O’Donell. (2007) The Journey to Creating a Campus-Wide Culture of Professionalism. Academic Medicine 82:11, 1015-1021
CrossRef104
Charles E. Christianson, Rosanne B. McBride, Richard C. Vari, Linda Olson, H David Wilson. (2007) From Traditional to Patient-Centered Learning: Curriculum Change as an Intervention for Changing Institutional Culture and Promoting Professionalism in Undergraduate Medical Education. Academic Medicine 82:11, 1079-1088
CrossRef105
Robin R. Deterding, Shale Wong, Glenn Faries, Jacqueline J. Glover, Timothy P. Garrington, Michael Wang, Marsha S. Anderson, Richard D. Krugman. (2007) The New University of Colorado Medical School Curriculum: A Pediatric Perspective. The Journal of Pediatrics 151:5, S32-S36
CrossRef106
Bimal Ashar, Rachel Levine, Jeffrey Magaziner, Robert Shochet, Scott Wright. (2007) An Association Between Paying Physician-teachers for their Teaching Efforts and an Improved Educational Experience for Learners. Journal of General Internal Medicine 22:10, 1393-1397
CrossRef107
Paul E. Ogden, Lauren S. Cobbs, Martha R. Howell, Stephen J.B. Sibbitt, Donald J. DiPette. (2007) Clinical Simulation: Importance to the Internal Medicine Educational Mission. The American Journal of Medicine 120:9, 820-824
CrossRef108
Brendan M Reilly. (2007) Inconvenient truths about effective clinical teaching. The Lancet 370:9588, 705-711
CrossRef109
Elizabeth H. Sinz. (2007) Anesthesiology National CME Program and ASA Activities in Simulation. Anesthesiology Clinics 25:2, 209-223
CrossRef110
Louis Weinstein, Honor M. Wolfe. (2007) The Downward Spiral of Physician Satisfaction. Obstetrics & Gynecology 109:5, 1181-1183
CrossRef111
D. Gorman, P. Poole, J. Scott. (2007) On the future role of the doctor. Internal Medicine Journal 37:3, 145-148
CrossRef112
(2007) Medical Education after the Flexner Report. New England Journal of Medicine 356:1, 90-91
Full Text113
Michael E. Whitcomb. (2007) Medical Education Reform: Is It Time for a Modern Flexner Report?. Academic Medicine 82:1, 1-2
CrossRef114
Rosalyn W. Stewart, Allison R. Barker, Robert B. Shochet, Scott M. Wright. (2007) The new and improved learning community at Johns Hopkins University School of Medicine resembles that at Hogwarts School of Witchcraft and Wizardry. Medical Teacher 29:4, 353-357
CrossRef115
Elizabeth Connor. (2007) Library 2.0. Medical Reference Services Quarterly 26:sup1, 5-23
CrossRef116
Olle Ten Cate, Steven Durning. (2007) Peer teaching in medical education: twelve reasons to move from theory to practice. Medical Teacher 29:6, 591-599
CrossRef117
Drazen, Jeffrey M., . (2006) A Good Teacher. New England Journal of Medicine 355:13, 1374-1375
Full Text118
Cox, Malcolm, Irby, David M., . (2006) A New Series on Medical Education. New England Journal of Medicine 355:13, 1375-1376
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