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Academic Medicine:
doi: 10.1097/ACM.0b013e3181c887f7
Flexner Centenary: Article

Professional Formation: Extending Medicine's Lineage of Service Into the Next Century

Rabow, Michael W. MD; Remen, Rachel N. MD; Parmelee, Dean X. MD; Inui, Thomas S. ScM, MD

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Author Information

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: mrabow@medicine.ucsf.edu.

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Abstract

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.

… 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 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.

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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

Table. List 1 Values...
Table. List 1 Values...
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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 Moreover, educators have long debated whether new values can be taught.14 While foundational values and service intention generally are established early in development and not newly acquired in medical school, they are tested in this environment and reconsidered in the context of physician responsibilities. As students develop professionally, however, they may also adopt new values from those modeled and accepted by their colleagues. In most schools, this process is informal, unsupervised, and accomplished without the explicit input of the professional community. Professional formation is an active maturational process, going beyond the preservation of empathy and compassion to support learners in moral development, including a deliberate and rigorous reexamination of the values, biases, and prejudices with which they may have entered medical school. Through candid discussion with other learners and faculty, individuals are enabled to examine their experience in depth and recommit to those values and beliefs they hold as true and appropriate.

Medical students must learn to identify the values at stake in a great variety of educational and clinical encounters, choose which to prioritize, and navigate situations appropriately when their personal values conflict with the norms of their new culture. For example, on the wards, students who enter medical school committed to treating patients with respect must decide how or even whether to respond when clinical supervisors (who assign them work, grant them privileges, and grade them) use disparaging jargon and labels to identify patients or request behaviors that violate the students' values. In a large study, more than one quarter of residents reported they had been “required to do something during the past year that they believed was immoral, unethical, or personally unacceptable.”15 Inui12 describes students as “struggling to keep one's balance in precarious situations.” Observing the general acceptance of professional behaviors in violation of expressed values creates moral dissonance.16 Students recognize differences between espoused ideals and discordant day-to-day behaviors but rarely receive guidance on how to respond to such experiences.10 The ways such sentinel moments of moral confrontation are negotiated has deep meaning for individuals, both students and faculty, and significant consequences for the profession at large. Ultimately, a consistent coherence between action and values identifies medicine as a moral enterprise and professionalism as a “moral commitment.”17

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Why Professional Formation Is Important

Professional formation enables scientific medicine to maintain its human relevance and to navigate the increasing complexities in social interactions. It encourages physicians to accord primacy to individual relationships and recognize nuance in decision making. The consequences of inadequate support for professional formation are profound and wide ranging, impacting individual learners, patients, the profession, and society at large.

Following one set of values in their personal lives and another in their work, students may become isolated, learn to wear a professional mask, or a “game face,” or begin to live a “divided life,”18 resulting in a loss of vitality and integrity.19 The discordance may become so stressful that learners narrow their focus to the mastery of simple technical or intellectual competencies without attention to relationships or deeper values or virtues.8 The potential outcomes of such discordance and disaffiliation include cynicism,20 depression,21 educational dissatisfaction,22 loss of empathy,23,24 crises of conscience,25 stunting of moral growth,26 and ethical erosion.27

Dissonance between the professed values of medicine and its actual practice makes it difficult for students to discern what values they are supposed to learn.3 With inadequate training in professional formation, feedback, or role modeling, students become vulnerable to unprofessional behavior themselves. Unprofessional student behavior has been identified as a marker for subsequent state medical board disciplinary action among physicians.28

Sacrificing foundational, personally meaningful values creates a loss of moral identity and self-trust, threatening a key physician skill—the professional use of self.29 When physicians are distanced from themselves and from such values as honesty and altruism, patient safety may suffer. Depersonalization, burnout, and poor patient care are linked,30 as are medical error and limited clinician self-awareness.31

When individual physicians cannot be counted on to act with personal integrity, not only is the doctor–patient relationship threatened,12 but the social contract with the profession of medicine is fractured as well.32 A personal adherence to service values is antecedent to a sustained professional commitment and is the foundation of the trust that the public has placed in our profession for generations. Our expertise makes us competent, but our values make us trustworthy.

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The Current Status of Professional Formation in Medical Education

Several major educational institutions establish the accreditation requirements that set standards for the learning environment in U.S. medical schools. The Liaison Committee on Medical Education (LCME) of the American Medical Association and the Association of American Medical Colleges (AAMC), the Accreditation Counsel for Graduate Medical Education (ACGME), the National Board of Medical Examiners (NBME), and various state medical boards require students to achieve well-defined core competencies in professionalism. The LCME accreditation standard MS-31-A is explicit about the need to promote the “development of explicit and appropriate professional attributes (attitudes, behaviors, and identity).”33 It is left to each medical school to define, measure, and document outcomes for these requirements.

Currently, most American medical schools offer either elective or required formal curricula that address aspects of professional formation, although evaluation of outcomes is limited.34 All schools must offer instruction in medical ethics, and many provide electives in medical humanities, spirituality, and integrative medicine. The Narrative Medicine curriculum at Columbia University,35 Mindfulness Training at Rochester School of Medicine36 and the University of Massachusetts,37 and the spirituality initiatives of the George Washington Institute on Spirituality and Health38 are prominent examples of professional formation programs. The Consortium for Academic Health Centers for Integrative Medicine includes 43 schools that offer research and teaching in this area.39 The national rituals and supplementary curricular experiences developed by the Arnold P. Gold Foundation, such as the White Coat Ceremony and the Gold Humanism Honors Society,40 also support professional formation.34

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Faculty in professional formation education

Faculty role modeling and mentorship are central to the professional development of students.7,41 Unfortunately, most faculty were not exposed to formation curricula as medical students themselves and are untrained in self-reflection, providing effective values-based feedback, or supporting professional formation.41 As students progress through medical school, an increasing percentage do not see their faculty as humanistic caregivers or good role models in teaching the doctor–patient relationship.42 However, there are a number of promising faculty development programs, including some which show evidence of improved humanistic teaching and institutional change.43,44 Elements of these successful programs include pairing experiential learning of skills with reflective exploration of values, values-centered medical education rounds and “think tanks” to promote buy-in, and faculty-wide workshops to teach content, examine teaching and evaluation strategies, and promote reflection and self-awareness.

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Two examples of formation projects

Among the many successful professional formation projects nationally, we will describe the two long-standing programs with which we are most familiar. These examples are presented in an effort to identify lessons learned and common elements that might guide the development of future programs.

The Healer's Art, developed at the University of California, San Francisco in 1991, is a 15-hour elective course for first- and second-year students now offered annually in 60 medical schools in the United States as well as schools in Canada, Israel, Slovenia, Australia, and Taiwan.45 More than 1,200 students complete the course annually. The Healer's Art uses experiential, contemplative, reflective, and narrative learning techniques and engages students in a discovery model (a “community of inquiry”) focused on professionalism and the shared core values that underlie medicine. The course includes five three-hour modules on topics such as preserving personal integrity and wholeness, meeting with loss, recognizing mystery and awe, and service and calling. The modules begin with a short and personal faculty statement on the session topic, called a “seed thought,” followed by a large-group guided reflection enabling students to explore their personal experience of the topic. The remainder of the session is spent in small-group discussion, sharing the critical incidents, personal experiences, and insights discovered during the reflection. Students are encouraged to develop habits of daily reflection through the use of a simple journal.

The small groups' size and format are designed to create interactional safety for both students and the faculty who act as small-group discussion facilitators. Formed via a random selection of five course participants, each small group begins by developing and agreeing to a set of guidelines for interaction that will allow all in that particular group to feel both safe and comfortable (e.g., confidentiality, not attempting to solve each other's problems, speaking from one's own experience, contributing by listening as well as speaking). Fundamental to the interaction is the principle of “generous listening.” Students are encouraged to suspend judgment, comparison, competition, and the need to fix others and simply listen in order to know what is true for another person. Faculty facilitators participate in the discovery model process not as teachers but as fellow learners and are trained (via a course director train-the-trainer model) to allow silence, speak sparingly, offer few if any comments borne of their faculty “expertise,” and gently encourage students to consider the deeper implication and meaning of their stories. Nationwide, both students and faculty report that the interactional safety they experience in their small-group discussions is unique in their medical school experience, furthers their self-awareness, deepens their affiliation to the profession and to each other, and diminishes isolation, enabling them to become genuinely known by colleagues. As one Healer's Art faculty commented, “This course heals loneliness, mine and the students'.”

The course is designed to enable medical students to directly experience and trust the power of presence and generous listening to heal, formulate a personal and compassionate response to loss, recognize awe and mystery in daily practice, and personally explore the concepts of calling, mission, and the life of service. The Healer's Art facilitates students in understanding that who they are as a person is central to the outcome of their work as physicians. Students also have the opportunity to reflect on and clarify the lifelong values that have brought them into medicine and to commit to further developing and preserving them as a way of life within medicine. In making personal values like service, harmlessness, compassion, and egalitarianism visible to others, students are often surprised to discover that such values are held in common by their peers and professional community and are, in fact, part of medicine's grand lineage.

During the past 19 years, the Healer's Art has been consistently evaluated highly by students and faculty at schools of widely varying sizes, locations, and cultures both here and abroad.46 Students commonly report that the course enables them to actually experience and practice what is only advocated elsewhere in their required curriculum. Review of students' course evaluations demonstrates that the course legitimizes humanistic elements of professionalism and creates a safe community for reflection, exploration, and discussion, enabling students to identify more completely with the underlying values and meaning of their work.47 During the final session of the course, students are invited to write a personal mission statement—often referred to as “rewriting the Hippocratic Oath.” Analysis of these mission statements reveals that students aspire to an expanded concept of professionalism that includes such elements as presence, awe, and love.48

A second professional formation initiative has emerged at the Indiana University School of Medicine (IUSM) and is focused on boldly remaking the educational environment, setting the stage for broad formal curricular revision as well.10,49,50 Recognizing the critical importance of the informal curriculum and the powerful influence of institutional culture on individual learning, the transformation at IUSM has involved every level of the learning and institutional community, from medical students to the dean and from faculty to service staff. Organizational change was initiated by a process more widely applied in the corporate world referred to as “appreciative inquiry,” an organizational development method in which individuals within the organization identify what is good about the existing system they want to promote, rather than focusing on what is not working.50 This process makes explicit the importance of values, remaining true to oneself, and participating in a community of shared respect. The wider cultural change effort has engaged many in the IUSM community retreats and in skill-building workshops for enhancing relationship-centered interaction.

In this organizational environment, it has been possible to establish a broad professionalism and professional formation curriculum. Inui et al10 have summarized one key component of this curriculum as “experience followed by reflection in a community of peers.” At IUSM, student values are supported in at least two ways, which represent a fusion of informal and formal curricula. First, medical students learn about the history of the profession and develop an understanding of their professional role. Second, students are encouraged to reflect on their experiences, through journaling and discussion of critical incidents. Ultimately, students become mindful of the “values embedded in actions.” The professionalism journaling now has become a standard requirement in several clerkships (internal medicine, surgery, psychiatry). In medicine, students gather in small dialogue groups monthly to choose narratives to read aloud and discuss. The dialogues cover all the professionalism domains thought important by the NBME.51

Faculty development efforts at IUSM, beyond the usual seminars that build faculty skills as teachers, researchers, and clinicians, have focused on a number of offerings that permit members of the IUSM to reconnect with their personal values, in effect to “show up at work as their whole selves.” Some faculty participated in the early appreciative inquiry activities and went on to skill-building workshops that strengthened relational work in all small groups, including “checking in” (beginning meetings with an opportunity to say whatever each person needs to say to be fully present), and appreciative debriefing of meetings (a lightening round of comments permitting each person to highlight the part of the work that captured their interests maximally). Faculty responded to the introduction of such simple processes with relief and enthusiasm. As one medicine faculty reported,

It was amazing to see the model in action. I loved the rituals of checking in, appreciative inquiry, and appreciative debriefing. Discovery Team introduced me not only to new ideas but to many important new relationships with people at IUSM whom I had never encountered previously.19

Formal faculty development programs at IUSM have included numerous nontraditional offerings, including: four Courage to Lead Retreat series (modeled after the work of Parker Palmer, and clearly focused on integrating personal values with professional work); a “change agent program” intended to develop skills among faculty for relational small-group leadership and conflict resolution (e.g., “polarity management”); professional development programs within the large academic health system clinical units focused on microsystem team trusting relationships and team building; a “generosity of spirit” conference open to clinicians and participants from the liberal arts campus; and a series of retreats open to medicine and nursing centered on humanities and the arts (music, water painting, poetry, mosaics—“wholeness from broken parts”). The core purpose of all such programming is to offer a variety of personal formation approaches to faculty, activities intended to invite their whole selves and values to be expressed in their work—with the assumption that such activities restore integrity and vitality to their daily work and enhance their ability to serve others. One medicine faculty member has said,

Most other faculty development workshops/retreats are very task-oriented and want their participants to learn and practice new/specific skills which they will hopefully implement into their work places, but they don't usually enable participants to arrive at that deeper place within themselves to fully experience that restorative power like the [IUSM] retreat.19

The organizational transformation at IUSM has been associated with improved student and faculty satisfaction, increased faculty vitality and dramatically increased medical school applications.52 In academic medical center “immersion conferences,” faculty teams from 25 other schools of medicine have traveled to IUSM to work together on methods of enhancing the professional values environment of their own schools.

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The Future of Professional Formation

It falls to each of us to make the practice of scientific medicine humanly relevant. Flexner recognized this responsibility 100 years ago. The challenge that lies ahead is nothing less than rebalancing the values of humanism and science and the development of innovative curricula to support the full power and scope of care that physicians deliver to their patients. It is possible that the future of professional formation may be grown from the seeds of what is currently working.

Training in professional formation is both experiential and contemplative, based on personal narratives, stories, and parables, focused on the integration of self, presence, and expertise, embedded in a learning community, and featuring candid discussion of critical incidents and personal experience within a safe, egalitarian community of learners.53,54 The central techniques of reflection and discussion of critical incidents are universally used to explore deeply held beliefs and attitudes of learners, with the goal of promoting sensitivity and commitment to the core values of both the individual and the profession, and the behaviors which embody these values.26,55,56 Faculty must develop the skills to help students identify the values incorporated in critical incident reports, paying particular attention to elements of discordance between the formal and informal curriculum, in order to clarify with students what they are to learn. List 2 summarizes the essential elements of professional formation education. Currently, many U.S. medical schools offer a number of these elements, but often electively or scattered within the curriculum. The true transformation in medical education will be to make professional formation education required and to hold both learners and teachers accountable for it. As has been shown at IUSM, such a coherent, schoolwide reformation is possible.

Table. List 2 Essent...
Table. List 2 Essent...
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The complete realization of Flexner's vision will involve changes at all levels of our educational system—from the new matriculant to the dean to the profession at large. Individual students can be encouraged to develop a daily practice of mindfulness and reflection.57 Such a habit, built into the practice of medicine, might include elements of proven curricular effectiveness, including journaling, reflection, storytelling, and critical incident review.56 Even in the setting of a harsh medical school learning environment, mindful students might themselves learn skills of discernment, self-awareness, and presence and strengthen their values commitment. Internet-based communication (including blogging and tweeting) offer exciting opportunities to promote reflection and discussion among medical students on a larger scale, but these opportunities also pose privacy and educational quality control challenges.58,59

Formal curricula in professional formation would require all students to explore values and learn discernment and equanimity in the context of competing ideals. Formation curricula would be integrated into basic science learning, as has been done in anatomy classes when students thank and/or memorialize the person who donated their body or when students meet the donor's family.60 Professional formation curriculum design should be based on careful evaluation and evidence of efficacy, including sustainable changes in student and faculty satisfaction, well-being, and behavior.3 Medical school accreditation standards will require evidence of positive outcomes and evidence-based curricula will need to be funded and widely disseminated.

Professional formation requires that students have an opportunity to experience positive role modeling, adequate mentoring, and authentic community to explore and discuss common values and struggles.26 Faculty development would require training in providing values-driven feedback and in serving as positive role models. Medical school faculty would be held accountable for a consistency between values and action and expected to behave and interact in ways coherent with what they teach. Such accountability might require clear expectations set by departmental leadership, academic credit for excellence in role modeling, as well as a work milieu supportive of critical self-assessment. A noncompetitive, safe, collegial faculty community is key. Learners would be encouraged to reflect on this modeling and openly discuss observed behaviors.61 Evaluation of professional behavior would be routine and coupled to remediation, consequences for unacceptable performance, and reward for achievement of the highest standards.34 An interesting first step in this direction is the Assessment of Professional Behaviors Program designed by the NBME to provide accurate and reliable multisource feedback to improve academic professional behaviors at the individual, departmental, and institutional levels.62

In a safe, diverse community, it is possible for individuals to assess the truth or appropriateness of their beliefs and values. Hearing and respecting the perspectives of others encourages learners to examine the negative biases that might underlie some of their behaviors and choices, encouraging students to remain committed only to those values that withstand a rigorous analysis of self within community. Incorporating collaborative, interprofessional teams into the learning community for medical students may expand perspectives in critical incidents and afford a greater sense of shared values between the professions. Teammates, including nonphysicians, may help medical students more clearly understand their role and relationship within health care and may challenge students to discover their unique professional identity and level of individual clinical responsibility.63 The future communities of inquiry for medical students will need to be reconciled with the widespread and growing use of social networking Web sites.64,65 It is not known how routinely networking over the Internet with both other students, lay peers, and perhaps even patients might impact the emerging professional identity of medical students.

An even grander future, closest to the original vision of Flexner, posits professional formation woven into the very fabric of the medical profession. Competency in professional formation would become a requirement for graduation and licensing. According to the architects of the IUSM curriculum, there are four domains of central importance to the moral development of physicians: (1) awareness and sensitivity, (2) judgment, (3) motivation, and (4) conduct.10 Through written discussion of critical incidents and professionalism evaluations, students could demonstrate their ability for self-reflection, discernment of relevant values, and actions they have taken based on their values. These elements might form the basis for evaluating competency in professional formation.

Successful medical education reform in the domain of professional values and personal commitments cannot proceed without widespread organizational change and addressing the hidden curriculum.66 Structures, cultures, and practices within medical schools, but also within the broader medical enterprise, will require exposure, study, and transformation to support a deep commitment to our highest values.67 Ultimately, such transformation will require a rebalancing of attention and financial support within medical schools and within our national medical institutions. While some cost-savings might be expected from the innovative use of Internet-based and electronic training materials and perhaps earlier specialized training among medical students, time and resources are required to promote professional formation. For each medical school, this represents a difficult prioritizing of important values within institutions, akin to the challenge facing individual medical students operating in complex environments when faced with multiple competing goals and principles. Such a process promises to reorient the moral compass of the profession and reinvigorate the public trust that Flexnerian reform established for the first time a century ago.68

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Closing Comments

Discordance between foundational values and daily practice likely contributes to the cynicism, depression, and dissatisfaction reported by medical students and faculty. Professional formation education in medical school engages both the student and the teacher and challenges each to grow and develop in ways that embody the highest ideals of the medical profession.69 The challenge of conflicting values is familiar to all physicians. We have all at some point been forced to reconcile our identity as physicians with our identity as people. We have all strayed at times from one or more of our own core values in the face of demands for increased productivity, academic competition, compassion fatigue, personal vulnerability, the needs of our families and friends, inexperience, or pure exhaustion.

In advancing professional formation, faculty will be called on to examine and respond to inconsistencies in what they teach and how they behave and will be invited to make explicit long-held values that motivate their behavior and professional choices. In a safe community of learners, faculty will be empowered to identify and constructively respond to behaviors among learners, colleagues, and themselves that they do not condone. We all, students and faculty alike, have something to learn and a shared need to reconnect to some of the values and commitments that originally called us all to medicine. Often, the “game face” for faculty involves their expertise, perfection, and easy ability to repress the emotional intensity of clinical medicine. Such expectations make it difficult for faculty to truly examine their work and their response to it, and to learn from and be inspired by students. As a faculty facilitator observed after teaching in the Healer's Art, “I had thought first-year students were naive about medicine. I think now that they know what it is really about. I had become cynical and I had not known it.” Learning in professional formation can only happen in an authentic community of learners at all levels of medical expertise, where faculty do not separate themselves from students, where all feel safe, facing their own acculturation and woundedness, where all support one another and share their dream of service.

Professional formation education offers both students and faculty the support to make their foundational values the principles of action in daily life and to bring their whole selves to work. The personal rewards of healing the divided life are integrity, self-respect, and connection. By weaving all of Flexner's remarkable vision into medical education, we will reclaim in the present the values that have distinguished the lineage of medicine over generations: compassion, healing, and service.

Funding/Support: None.

Other disclosures: Dr. Rabow is the director of the Center for the Study of the Healer's Art. Dr. Remen developed and directs the Healer's Art course nationally. Dr. Parmelee is a Healer's Art course director at Wright State University Boonshoft School of Medicine. Dr. Inui is the associate dean for health care research at Indiana University School of Medicine.

Ethical approval: Not applicable.

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