Curry, Raymond H. MD; Montgomery, Kathryn PhD
Abraham Flexner's central thesis in his analyses of North American and European medical education was that medical schools should be “organic parts of full-fledged universities.”1 This conviction was aimed, first and foremost, at the inclusion of an education in the “laboratory branches” and the integration of scientific research into the schools. Connections to the university environment also facilitated the pursuit of two related goals: preliminary university study and a dedicated medical school faculty along a full-time university model.2 Although this agenda had already begun to drive the development of American medical education before Flexner's 1910 report,3 his comprehensive exploration firmly established the university model in North America. The model was reinforced by his later (1925) comparative study of schools in Europe and the United States.4
To this day, these aspects of “Flexnerian” medicine carry excellent connotations, describing a professional education that is anchored in academia and that bases its teaching programs and advances in practice on the scientific knowledge promulgated and advanced by the academy. Even community-based schools generally follow this pattern and seek strong university alliances. Whenever American medical education is lauded as the best in the world, this close partnership with scientific research and discovery is understood to be the foundation of its success.
But are medical schools, a century after the 1910 report, taking best advantage of the university affiliations Flexner promoted? In considering what the university has to offer, along with shortcomings many educators see in current medical curricula, we imagine the medical school years as an opportunity for a liberal education in medicine. After describing a few post-Flexnerian changes in curricular content, we will invoke Flexner's spirit—and a few prescient observations from his later writings—to propose pursuit of this goal through further contributions of the university at large to undergraduate medical education.
Curricular Evolution Beyond the “Laboratory Branches”
The narrowness of Flexnerian medicine's scientific focus provoked comment right from the start. By 1927, Peabody5 had famously noted the science overload and stressed the need for primary attention to the patient. Flexner himself came to recognize the imbalance. In his 1925 study, he found “scientific medicine in America... today sadly deficient in cultural and philosophic background,”4 and perhaps he had never intended that this bias would develop.3,6 In 1935, L.J. Henderson,7 whose contributions to acid–base physiology (viz. the Henderson–Hasselbach equation) are at the core of every medical student's science education, also argued for attention to the social sciences, particularly the underpinnings of clinician–patient communication. By the 1950s, communication skills were indeed part of most U.S. curricula, though usually only of interest to the psychiatric faculty. In the 1970s, George Engel's8 biopsychosocial model provided the theoretical base for a richer conception of medical practice and encouraged explicit attention to the patient–physician relationship. Humanities disciplines—ethics, literature, history, religious studies—were introduced as electives in the 1970s and began to flourish in the 1980s and 1990s.
These developments are part of a historical trajectory that began with the initial introduction, long before Flexner, of “basic” sciences into the medical curriculum at Harvard. And, just as Oliver Wendell Holmes, Sr. and his colleagues, products of the prevailing empirical American education, objected to the study of the experimental sciences as irrelevant to the needs of clinicians,3 so these later additions have met on occasion with skepticism and disdain. Thus, whereas accreditation requirements now address prevention, communication, medical decision making, ethics, and cultural competence on equal footing with the basic sciences, the reality, driven by licensing examinations and by the research-intensive world inhabited by the academic faculty, is significantly different. Nonscience disciplines often are incorporated in fragmented and superficial form, taught by clinicians who may have an abiding practical interest but rarely the academic background or expertise we would otherwise expect of teachers at the graduate level.
Defining Liberal Education
The liberal medical education we envision would further complete this historical trajectory from simple apprenticeship to a broadly conceived education. We affirm the American Association of Colleges and Universities' description:
Liberal education is an approach to learning that empowers individuals and prepares them to deal with complexity, diversity, and change. It provides students with broad knowledge of the wider world (e.g., science, culture, and society) as well as in-depth study in a specific area of interest. A liberal education helps students develop a sense of social responsibility, as well as strong and transferable intellectual and practical skills such as communication, analytical and problem-solving skills, and a demonstrated ability to apply knowledge and skills in real-world settings.9
This account recaptures the emphasis on intellectual exploration that was the hallmark of the Germanic experimental approach so attractive to 19th-century American medical education reformers, and it does so in a manner inclusive of the physical, biological, and social sciences—a much broader reach than the exclusive focus on the humanities too often equated with “liberal” education.
Several aspects of this definition invite application to both historical and current thinking about medical education. It identifies the development of social and cultural perspective as the primary goal of a broad disciplinary base—a goal clearly synchronous with current efforts to ensure “cultural competence” in our medical students. This is coupled with the need to pursue expertise in a more focused area, where learners are explicitly identified as individuals, empowered to follow their own interests in health and medicine—a representation of one of the main tenets of learner-centered learning10 that calls to mind the recent development of “scholarly concentrations” or “tracks” at several schools. Finally, the definition emphasizes translation from the world of scholarship to effective problem-solving and meaningful work in the real world. For medical educators, this quickly brings to mind a main thrust of the 1984 Report on the General Professional Education of the Physician (GPEP),11 the document that fueled much useful curricular reform in the latter part of the 20th century.
Each of these aspects of liberal education—disciplinary breadth, social and cultural perspective, learner-centeredness, and translation to the work of a skilled professional—has the potential to broaden and enrich the education of physicians.
Disciplinary Breadth and Cultural Perspective
The report of GPEP's Working Group on Personal Qualities, Values, and Attitudes, included as an appendix in the 1984 summary report,11 contains perhaps the first “mainstream” call for expansion of social sciences and humanities content in medical curricula, to be accomplished by “mobilization of faculty resources from other departments and schools.” Though only vaguely echoed in the main GPEP conclusions, in a call for “shifting emphases” away from factual, biomedical information, the report's perceived stance on the respective roles of the sciences and other disciplines still drew criticism—and from both directions. In one early response from medical school deans and academic leaders, the report was seen as neglecting the basic sciences in the education of doctors.12 Charles Odegaard13 saw it quite differently:
One cannot escape the conclusion that in this Report the Flexnerian form of medical education with its exclusive concentration on disease as simply a malfunction of the organs and tissues of the body interpreted in the light of findings based on the biological, chemical and physical sciences was accepted without any need for comment. The panel in its report simply did not subject it to critical review.
The “tension that existed between these two camps in the 1980s,” notes Whitcomb14 in a recent editorial on the 25th anniversary of the initiation of the process that led to GPEP, “persists today.”
As we have outlined above, the disciplinary breadth of medical curricula did nevertheless expand a good bit in the ensuing two decades, though perhaps not always with appropriate intellectual rigor and often subject to the continuing tension identified by Whitcomb. The recent emphasis on “cultural competence” in accreditation standards and curricular objectives may help further illustrate this status quo. Few would argue the urgency of this agenda, in the face of undeniable evidence that physicians' knowledge deficits, biases, and inattentions contribute to suboptimal and inequitable health care. There may be danger, however, in simply incorporating learning objectives in social and cultural aspects of health care into the outcomes-based competency frameworks now driving much of professional education. Kumagai and Lypson15 describe a broader “critical consciousness” required to learn the social endeavor that is medicine, and ask us to avoid reducing these essential aspects of a professional education to another set of observable knowledge, skills, and attitudes, to be considered alongside the student's ability to perform an abdominal examination.
The heart of Flexner's vision for medical education involved the development of an intellectual curiosity and fueled the change from an empiric, trade school model to a genuinely scientific approach as physicians realized they needed to think critically about the biological systems they were tampering with in treating patients. Our students now need also to learn to think critically about the perceptions, experiences, and needs of patients as individuals who are complexly situated in a cultural matrix of meanings and expectations—a sort of critical thinking that cannot be achieved through a few class sessions addressing cultural awareness in health care settings. Renée Fox16 suggests that each student have occasion to study in depth “at least one society other than one's own” and also describes students' need to understand the professional culture medicine constructs around itself.
The full realization of a “general professional education” would allow students to explore any of the disciplines related to medicine in a manner that would broaden and enrich their careers, without necessarily incurring the premature narrowing of specialization. Students might explore issues of stigma or disability, or the economics of health care. Those interested in pediatrics could study the history of childhood, cross-cultural breastfeeding practices, or public policy that affects children's health. The possibilities are legion, and few (geology, perhaps?) are irrelevant to clinical practice, medical research, or the societal contributions of the profession.
Many of these learning goals can of course be addressed before medical school. The GPEP Report, in fact, called for a broadening of the premedical experience. Such calls continue, some focusing on the relevance of traditional prerequisite coursework to the selection and success of medical students, and others thinking beyond this to a more active integration of subjects relevant to medicine across the premedical/medical school continuum. Ezekiel Emanuel17 recommends replacing the premedical requirements of calculus and organic chemistry with statistics, genetics, and molecular biology and including bioethics, communication, management skills, and finance in the required medical curriculum. The Association of American Medical Colleges (AAMC), in collaboration with the Howard Hughes Medical Institute, has recently released a report on the Scientific Foundations for Future Physicians18 that addresses premedical science preparation in a competency-based rather than course-specific manner, recognizing the potential for an effective premedical-to-medical school learning continuum and respecting, if not enhancing, opportunities for liberal education in the premedical years. A parallel examination of preparation in the social and behavioral sciences is forthcoming.
In any case, students' pursuit of liberal education's goals should not be limited to their premedical years. This perspective is by no means new. In “The medical school and the university,” Sherwin Nuland19 describes Dean Milton C. Winternitz's attempt to establish an Institute of Human Relations at Yale in the 1920s and 1930s, merging medical studies and the university toward the study of patients as whole people in their social and economic contexts. The effort failed (Flexner, despite a long friendship with Winternitz, was a prominent opponent),20 but Nuland's essay makes a fine case for a renewed attempt. In 1959, Stanford added a fifth year of elective study to its medical curriculum. Among its objectives were “to bring medical education into the University environment... and relate knowledge of the medical sciences to other fields of knowledge,” and “to foster a graduate approach to medical education.”21 In practice, the main result was an extension of the basic-science-focused portion of the curriculum from two to three years, with inadequate collaboration between departments in the presumably interdisciplinary courses, and the effort was abandoned by 1968.22
Learner-Centered and Individuated Education
Liberal education's focus on empowerment of the individual student is best expressed through the principles of learner-centered learning, which begin with the uniqueness of each student's prior experience and goals and place a great deal of the responsibility for pursuit and assessment of those goals on the student.10 The importance of focused, in-depth study in an area of interest to the student follows naturally from this approach.
Learner-centered learning principles have clear applicability in professional education, where learners are adult, postgraduate students and a clear expectation of continuing professional education comes with the territory. In health professions education, there is also a useful parallel between learner-centered educational principles and the patient-centered approach to care. A number of successful educational programs, most notably in health communication, have wedded these approaches.23
The adoption of a learner-centered approach to medical curricula in general has been limited, however, by the enormous amounts of information, both factual and conceptual, potentially to be included in the required curriculum,24 a reality that leads many educators to fear that students' pursuit of individualized agendas will result in an incomplete education. It is useful in this regard to return to the GPEP Report and its conception of the “general” professional education of the physician. The GPEP Report strongly advocated independent learning, a limitation of the amount of material students are expected to memorize, and a focus on fundamental clinical skills and professional perspectives applicable across all medical specialties.11 In practice, rather than bringing about a more concise, common curriculum of fundamentals beyond which students can then begin to differentiate according to their personal goals, the GPEP's advocacy of “general education” for physicians seems often interpreted to mean that those at the point of receipt of the MD must be capable of entering postgraduate training in any discipline.
The result, inevitable in medical curricula thus overcrowded with required content, is a lockstep curriculum that looks the same for most every student, with limited opportunity for pursuit of individualized interests and learning goals in a true learner-centered manner. The small-group, discussion-oriented seminars and problem-based learning sessions many of us proudly point to as evidence of a commitment to progressive learning principles are still part of a required curriculum that occupies the overwhelming majority of students' time in the first three years at almost every school. Most real flexibility for the pursuit of students' individual learning goals is little more than a pregraduation afterthought in the fourth year. Those who wish to explore laboratory research in more depth, pursue international experiences, or study allied disciplines usually must absent themselves from the curricular mainstream. Flexner, contrasting in his 1925 study the more experimentally based German system with the uniform expectations already established in the United States, poked a bit of fun at the latter:
A student who entered an American medical school with the “Class of 1922” would, generally speaking, be a homeless waif if, interested in physiology, he paused for a year and thus had, the next year, to domesticate himself with the “Class of 1923.”4
We suggest a middle ground in defining the “general” professional education, one where medical graduates might be pluripotential but need not be totipotential. Some might recognize early on, for example, that they will not be pursuing a procedural specialty; expectations for their demonstration of technical skills prior to residency application might be modified accordingly. The duration and scope of each introductory specialty clinical experience should be carefully tailored to the learning needs of those who will not necessarily practice that specialty. Such an approach recognizes the need for all physicians to have a broad understanding of the profession and still allows the expression of students' individual lived experiences, educational background, and professional goals. Not incidentally, it also facilitates the appropriate education of students with physical or sensory disabilities who might become outstanding physicians but for an inability to meet certain technical standards for admission that pertain mostly to procedural specialties.25
Opportunities for change along these lines are emerging. Several schools have recently created selective opportunities for academic concentration during medical school, allowing students to differentiate their interests and focus in very much the way we are advocating. These opportunities should be designed to encourage utilization of the resources of the university to the greatest extent possible, even bringing students from different graduate-level disciplines together in collaborative study. They should not simply be “tracks” toward early specialization; they should be understood as opportunities for expanding the tools and perspectives students will bring to whatever medical specialty they pursue. A global health concentration, for example, could be prelude to a career in dermatology as easily as one in emergency medicine; a women's health concentration could be invaluable to a urologist or internist as well as an obstetrician–gynecologist. In some cases, additional study beyond the selective requirements of the medical school might lead to an additional graduate degree, as is becoming more prevalent with combined MD and master's degrees in public health, business, and the medical humanities.
This addition of features more typical of graduate education—or, when offering medical students combined degrees, the inclusion of graduate education per se—may seem to threaten a “de-professionalization” of medical education. To the extent that the profession still considers itself the guardian of a discrete (if enormous) body of knowledge and set of skills, or sees self-replication as a primary goal, this may be true. But the relationships of health, disease, pain, and suffering to a multitude of other scholarly and professional disciplines belie the former notion, and the pace of change in the profession itself challenges the latter. Instead, the preparation of physicians to deal with “complexity, diversity, and change” inherent in a liberal model represents a substantial and transformative higher standard of professionalism—not unlike the transformation from tradesman to scientifically engaged practitioner Flexner helped to bring about.
These ideas might also seem to conflict with current efforts to structure medical curricula according to well-defined competencies that every student must achieve. In keeping with those who believe “competency” is a bar set too low,26 we would see the achievement of general competencies as a curricular core and would expect every student also to pursue a path of individual discovery and scholarship beyond that level. Appropriate use of a core competency framework can also free the curriculum from specific course requirements to some degree, by specifying learning outcomes that can then be met through a variety of selective or elective routes.
There is little danger that preparation for practice would be weakened. For decades now, graduate medical education has been a universal expectation for licensure in this and most other countries, such that the medical curriculum is the defining, but not the ultimate, stage in a continuum involving college, graduate and professional, postgraduate, and continuing education opportunities.14 The increasing rigor of outcomes assessment in graduate medical education, and the parallel development of meaningfulskills and outcomes assessments in specialty certification and recertification, will make these latter stages in the educational continuum increasingly important, and sufficient, for ensuring physicians' preparation for specific practice environments.
Meanwhile, a more liberal approach to the MD curriculum will foster more attention to the broader roles and responsibilities of the profession in society. Rudolph Virchow, on his election to the Prussian parliament in 1848, famously defended this apparent distraction from professorial life by proclaiming that “medicine is a social science, and politics nothing more than medicine on a grand scale.”27 We can hope that a generation of medical students who will have learned medicine in this broader context will, among other things, help connect the historical divide between public health and medicine in this country,28 or participate more broadly in the body politic.29
The Role of the University in Medical Education
Effective provision of opportunities for study beyond areas usually represented within medical schools themselves will require expanded interactions between medical schools and their parent universities. To that end, it is worth exploring the extent to which North American medical schools are in fact the “organic parts of full-fledged universities” Flexner promoted. Working from the characterizations of schools in the AAMC Directory of Medical Education30 and from the most recent Carnegie Classification of Institutions of Higher Education,31 one finds 27 of the 130 U.S. medical schools accredited or provisionally accredited by the Liaison Committee on Medical Education identified solely as “Special Focus/Medical” institutions—self-contained health professions centers—by the Carnegie Classification. Four are affiliated with master's-level institutions, and the other 99 with doctoral-level research universities. Even then, a number of those latter schools are scores of miles from the rest of their university. The point is not to denigrate those medical schools outside the realm of a comprehensive university but, instead, to reflect on what impact such proximity now has on curricular content and other aspects of the medical education experience. Aside from the relative ease of creating programs of joint study or joint degrees with public health, engineering, business, and the like, medical schools with ready access to the rest of the university are seemingly not going about it any differently from those that do not.
A liberal medical education model would need to be accompanied by access to faculty across the university or, where that is difficult to achieve, by faculty who, like the scientists added 100 years ago, can bring new disciplines to the medical school. The situation in bioethics and the humanities, with small faculties now commonly located within medical schools, offers a contemporary model of the latter approach. Schools without comprehensive university relationships should not find it difficult to create, at minimum, focused affiliations in the areas their students will most often pursue.
A general medical education involves, first and foremost, the assurance of competence in core knowledge, skills, and perspectives. The next frontiers for medical education will require more emphasis on nurturing students' intellectual curiosity about phenomena of illness and disease, their understanding of the human condition, and their exploration of the many other disciplines that relate to medicine and the life sciences. These are learning needs that could be met at least in part through more flexible and individualized paths to the MD.
Medicine will never achieve liberal education's traditional ideal of knowledge for its own sake. A medical education will always fundamentally be a professional education, with its inevitable and quite necessary utilitarian aspects. But we have not taken full advantage of our academic citizenship. As the boundaries of the profession's interests and interconnections expand, the utility of this wider variety of skills and perspectives for future physicians will grow, as will society's need for physicians who carry with them the wonder, inquisitiveness, and ability to think critically that are the essence of a liberal education.
The authors are grateful to a number of colleagues who helped shape and refine these ideas through two colloquia held by Northwestern's Medical Humanities and Bioethics Program; special thanks are due for the incisive critique of Catherine M. Wallace, PhD.
Other disclosures: None.
Ethical approval: Not applicable.
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