To the Editor:
Whitcomb1 raised the intriguing issue of how Abraham Flexner might approach a contemporary study of medical education and suggests that Flexner would focus only on graduate medical education. I believe Flexner would approach the issue a bit differently, guided by at least three principles, each of which shaped the character of his earlier work.
Flexner would still maintain that the essential goal of medical education is to prepare learners for practice, but at both levels. Recognizing the enormous growth in volume of clinical understanding and care techniques, he would accept our expanded period of education and the need for greater specialization with an increasing division of labor. However, he would seek to ensure that clinical education provides a continuum of practice preparation, not unconnected pre- and postgraduate experiences.
Second, he would criticize us for failing to adhere to his principle that any clinical act is an applied activity that requires the aspiring clinician to learn to apply scientific understanding to the care of each patient:
An education in medicine nowadays involves both learning and learning how; the student cannot effectively know, unless he knows how.2 (p53)
Flexner would be horrified with the amount of emphasis on knowledge acquisition in the undergraduate curriculum at the expense of experiential clinical learning. Flexner was one of many who believed in “reflective practice” long before it became popular. Remarking on our newfound ability to access information at the press of a button, he would wonder why students are not permitted to spend more time in learning to apply it.
Finally, for the many reasons stated by Whitcomb, Flexner would urge both graduate and undergraduate medical education to reconsider the needs of society in designing their educational programs. One hundred years ago, the care of the acutely ill patient, particularly in the hospital setting, was the main focus of clinical education. Our ability to address the health care needs of patients has greatly expanded to include much more acute, emergency, and chronic care, particularly in the outpatient setting; critical and palliative care; population and community-based care; and preventive and wellness care. Flexner would want us to organize medical education all along the continuum so that each of these health care needs would provide learning opportunities. Also, he would be quite disappointed that the dominant forces influencing the educational design priorities of our teaching institutions are, once again, peer status and profit motive.
Eugene C. Corbett, Jr., MD
Brodie Professor of Medicine, professor of nursing, and assistant dean for clinical skills education, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; firstname.lastname@example.org.
1 Whitcomb ME. Commentary: Flexner redux 2010: Graduate medical education in the United States. Acad Med. 2009;84:1476–1478.
2 Flexner A. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston, Mass: Updyke; 1910.