A genuine higher education for the professions will not be content with reflecting the professionally defined competencies but will assert alternative modes of reasoning, action, and reflection into the curriculum.
—Ronald Barnett, The Limits of Competence: Knowledge, Higher Education, and Society, 19941
At its core, medicine is a human science. It is the application of science in the service of human needs and interests in order to alleviate suffering and optimize health. Medical education therefore involves teaching individuals to acquire not only knowledge of the biomedical sciences and skills in clinical application but also the ability to practice medicine in an ethical, responsible, empathic, and just manner. This latter requirement involves education in medical ethics, professionalism, the doctor–patient relationship, issues of diversity and social justice, and other areas of medicine that have social and societal relevance.
How does one educate physicians to excel in all of these very disparate areas? Currently, the predominant approach is the competency model,2,3 which is based on a functional analysis of the professional activities and roles of the physician, development of educational outcomes based on these roles, and assessment of medical trainees’ progress in achieving these outcomes in demonstrable, reproducible ways. However, one is compelled to ask, is the competency model truly appropriate for all of the types of knowledge necessary to become and be a good physician?
The goal of this article is threefold: first, to explore the nature of knowing and the goals of education in different areas of medicine and, in particular, those areas that have societal or social relevance; second, to critically review the concept of competencies when applied to education in socially relevant areas of medicine; and third, to discuss alternative strategies for teaching, learning, and assessment in these areas.
Different Ways of Knowing
In implementing educational programs to teach medicine-as-human-science, there arises a question of epistemology: Is knowledge gained from the study of basic and clinical biomedical sciences different from that acquired in studying areas of medicine that have social and societal relevance? For example, is knowledge of the pathophysiology of heart failure different from knowing how to implement current practice guidelines in managing type 2 diabetes or from a sensitivity to possible obstacles in accessing health care encountered by communities of color and a commitment to advocating for their needs and health? What about the knowledge of how to comfort parents who were just informed of the death of their child or the difficulties involved in addressing ethical issues in clinical practice? The question about whether or not there are different types of knowing is not merely an academic one, because an understanding of what is taught is central to how these latter subjects are taught, learned, and assessed.
To clarify the different ways of knowing in medical education, it would be fruitful to draw on the early work of the German critical theorist Jürgen Habermas. In Knowledge and Human Interests, Habermas4 argues that knowledge is not generated in a value-free vacuum; rather, it is created in response to specific interests or goals. He posits that all knowledge that influences human action is driven by one of three categories of cognitive interests—instrumental, communicative, and emancipatory—and each category of cognitive interest generates a unique form of knowledge used by individuals acting in the world (see Table 1).*
Instrumental interests generate technical knowledge whose goal is the understanding of, and technical control over, natural processes. This type of knowledge is validated using approaches of classical experimentation (i.e., observation, hypothesis generation, and testing) and is the dominant approach in the natural sciences. Communicative interests generate practical knowledge whose goal is to orient actions within common traditions and to foster consensus. Areas that are subject to this approach, such as history or the social sciences, are studied through techniques that verify the validity of statements or actions with respect to a consensus regarding specific areas under consideration—that is, how new ideas or actions “fit” within a greater agreed-on tradition. Finally, emancipatory interests generate critical knowledge, whose goal is to link knowledge and learning together with human interests and needs in order to free human beings from suffering, oppression, and injustice.4
Viewed from this perspective, knowledge that forms the foundation for medical school curricula may be classified into technical, practical, and critical types (Table 1). Technical knowledge arising from instrumental interests includes the vast breadth of the biomedical sciences and clinical medicine, which is validated through basic science and clinical experimentation. Practical knowledge arising from communicative interests may be broadly interpreted to include areas of learning and practice whose standards are based on consensus and include standards for learning (e.g., most “competencies”), diagnostic criteria, and standards of clinical practice. The validity of this type of knowledge is provided by, for example, an expert consensus statement or a commonly shared understanding of what constitutes the standards of best practice. Obviously, there is a fair amount of overlap between these areas of knowledge. For example, meeting a consensus standard regarding the optimal performance of a physical exam requires a thorough understanding of the pathophysiological processes leading to physical manifestations of disease, and standards of clinical practice are informed by evidence derived from clinical trials. Nonetheless, the basic interests or orientation and ways of validating these types of knowledge differ in their relative emphasis.
Although much of the learning in medical training is appropriately directed toward technical knowledge and a communicative, consensus-based understanding of best clinical or educational practices, not all of the education necessary to prepare physicians to work in today’s society arises from instrumental or communicative interests. Implicit in the efforts to introduce more humanistic care into medical education and to address topics in medical ethics, professionalism, and multicultural education is the introduction of human values into professional training—that is, efforts in education and practice directed toward addressing human needs. Therefore, the type of interest that constitutes these efforts, according to Habermas’s4 conceptualization, is emancipatory. This emancipatory interest is expressed, and the critical knowledge it engenders is fostered, through self-reflection and discourse and anchors a reflective self with others in social and societal interactions.5 In the biomedical or clinical sciences, the basic orientation of knowledge is fundamentally different than in multicultural education, professionalism, medical ethics, and other areas that incorporate humanistic values in medical education and practice. In the former, knowledge may be acquired and used without an explicit connection between the practice of medicine and societal needs, whereas in the latter, the goals of medical education are directed toward fostering critical self-awareness, acquiring an understanding of social issues (both interpersonal and societal) in medicine, and developing an individual approach to reflective, ethical practice.
This is not to say that emancipatory interests and the knowledge they create are “better” or more important than knowledge generated by instrumental or practical interests. All of these forms of knowledge—as well as the interests that drive their acquisition—are essential to the development of skilled, committed, humanistic physicians. The purpose of creating this epistemological topology is to emphasize the different ways of knowing that are included in medical education—ways of knowing that require different pedagogical approaches and means of assessment. A second rationale for such a topology is to underscore the risks that an exclusive emphasis on specific ways of knowing has on learning in other areas. The instrumental approach predominates most aspects of medicine—and appropriately so; however, an exclusive emphasis on what Schön6 calls “technical rationality” as the basis for patient care threatens to overwhelm and distort learning and understanding in socially relevant areas of medical practice.
The Development of a Professional Being-in-the-World
So what is the object of learning derived from emancipatory interests? In curricular subjects from professionalism to doctor–patient communication to issues of social justice, this type of learning does not involve just knowing facts, figures, and concepts or the acquisition of a specific set of skills. On the contrary, it involves the development of a fundamental personal and professional orientation towards self and others—a way of being in the world—in which the practice of medicine always has human interests front and center. This way of being cannot be taught didactically through lectures and assessed through multiple-choice exams but must be acquired tacitly through reflection, dialogue, and experience.
According to Polanyi,7 tacit knowledge is based on the fact that “we can know more than we can tell.” In contrast to knowledge that is explicitly known and easily recalled, tacit knowledge exists deep in memory and consciousness and stems from the interactions between an individual and his or her environment. Polanyi posits that tacit knowledge consists of two interrelated parts: a “proximal term,” of which we are aware only through its effect on a second, or “distal term,” whose presence is mediated by the first.7(p9) To illustrate this point, Polanyi uses the example of a blind man walking with a cane.7 The individual negotiates the world by tapping with the cane in order to perceive what is around him. In this case, the immediate sensation that the tapping of the cane produces in his hand is the “proximal term,” and the surrounding world—the object to which he ultimately attends—is the “distal term.” Polanyi states that although the individual attends from the tapping of the cane to the surrounding world, it is only through his reliance on the proximal term that he learns of and knows the distal term—that is, the world. In other words, our understanding of the world (the distal term) is mediated by our ways of approaching the world (via the proximal term, “tapping”); however, it is only the distal term—the world—that we are conscious of and can “tell.”7
Although Polanyi asserts that tacit knowledge is an essential part of all knowledge, his concept of tacit knowing is particularly relevant in the types of learning that involve societally relevant fields of medicine. The knowledge and orientation—the ways of being in the world—for the professional are a proximal referent to a distal action—that is, caring for patients. The disposition that one acquires through training with regard to patients—humanistic, dedicated, ethical, judicious, or their opposites—are the oft-unconscious ways in which one attends to the distal term—the practice of medicine. We know both of these things—dispositions toward others and caring for patients—but only one (the second) we can tell (i.e., that rises to our awareness). Polanyi7 posits that when we make a thing function as the proximal term of tacit knowing, we incorporate it into our selves so that it comes to dwell within us. This central concept of “indwelling,” Polanyi asserts, plays a critical role in the “interiorization” (internalization) of moral lessons:
To interiorize is to identify ourselves with the teachings in question, by making them function as the proximal term of a tacit moral knowledge, as applied in practice. This establishes the tacit framework for our moral acts and judgments.7(p17)
It is precisely this acquisition of tacit knowledge that confers such power to the “hidden” or “informal” curriculum.”8,9 Values, perspectives, and worldviews about oneself and others in medicine tacitly learned through interactions during clinical training persist because by being tacit, they are buried deep—and dwell within—us and, as such, are not normally subject to conscious critical questioning. The challenge, then, is to bring the most negative, dehumanizing lessons learned through interaction with the “hidden curriculum” under critical, humanistic inquiry.
Competencies and Emancipatory Ways of Knowing
So how do these goals fit into current models of competency? Although there are a number of different definitions of competency10 and competency-based education,2,11 several themes are consistent. One: There is an emphasis on the outcomes achieved as a bench mark for progress rather than the under lying learning process itself. Two: Out comes must be observable. Under lying competence is then inferred from observable actions. Three: Standardi zation of outcomes and assessments is a priority, as is the generation of “objective” data. Four: A learner’s progression is measured in terms of fulfillment of com petencies rather than the time taken to achieve these goals.
With its emphasis on standardized metrics and benchmarks, competency-based education has been proposed as a means of investing students in their own education and placing undergraduate medical student education on par with postgraduate training as an educational priority.12 Numerous organizations have called for competency-based education,11,13–15 and there is an increasing reliance on competencies for program assessment and accreditation; however, there is by no means universal acceptance of the concept. Competency-based efforts have been criticized both in general education1,3 and in medical education16–19 for a reductionist approach that ignores the complexities of human behavior and professional understanding1 and that runs the risk of neglecting “a deep and reflective engagement” with critical aspects of professional practice.19
My purpose here is not, however, to throw additional grist onto the mill regarding whether the competency model is the most appropriate for medical education as a whole. Indeed, in the areas of biomedical science and clinical skills, competency-based approaches may help to define the objectives—and to a certain extent, the methods—which may be used to achieve a specific educational outcome. However, the present focus is on the question of its appropriateness for education in the areas of medicine of social relevance.
Developing new ways of seeing and knowing the world depends on a variety of different factors. The background of the learner is essential in this process. The interactions between an individual’s personal worldview with new situations, ideas, and perspectives are critical factors in determining the “form that transforms”20 in learning.
So how does this type of development fit within a framework of competencies? First, development of this orientation emphasizes process rather than exclusively outcomes and is individual and unique. Each individual forms a professional identity and worldview that is personal and heavily influenced by individual background, values, beliefs, and life experiences. Although there are clearly overarching qualities which we would expect all physicians to strive to acquire (e.g., compassion, integrity, duty, accountability), the expression of these qualities in practice takes on a highly individual character. In contrast, the idea of competency requires a standardization of norms and outcomes—the idea that all students must meet a consensus-derived minimum standard in order to advance.
Second, in a related manner, this type of orientation is internally derived. Each learner interacts with his or her environment and others in order to find the individual moral perspective that comes to dwell within the self. This is in contrast to the idea of competencies, in which it is the learner’s task to fulfill predetermined standards rather than to grow into excellence on one’s own.
Third, lessons acquired through this process reside deep within the self. In distinct contrast to the requirement of observable outcomes, these lessons cannot be called forth as easily as facts on a multiple-choice exam or enacted as simply as the performance of a skill in a standardized setting. As Barnett1(pp75–76) asserts:
We cannot know what individuals as social actors are up to by observing them, even if they act in statistically regular ways. Ultimately, we shall only fully understand their actions by taking account of their definitions of their situations, of their intentions, of their conceptual frameworks and of their forms of life. Full understanding requires that we understand the individual’s understandings. Real work or real competence cannot be read off from activities from the outside. It cannot be seriously assessed by observing it.… It is not that the understandings lie behind the action. It is the much stronger claim that the actor’s understandings are constitutive of the action.
Fourth, this process is never-ending. Unlike with the idea of competency, which connotes completion, one can always add to one’s understanding of oneself and one’s profession and enhance this understanding through reflective practice, dialogue, and experience. This overall perspective is in agreement with Wear and Zarconi’s21 assertion that there are areas of medical education involving reflectiveness, inquisitiveness, and imagination that should be “off limits to the competency gaze.” This is not only because the competency model provides overly literal, stifling limitations on the exploration of the human side of medicine but also because its emphasis on observable outcomes, standardization, and externally imposed criteria in these areas is the wrong tool for a different, and no less valid, epistemology.
So, what does this education look like? In keeping with Habermas’s idea of ways of knowing that are driven by emancipatory interests, this type of education encompasses reflection, imagination, and discourse. It engages learners and teachers in all their individual complexity and uniqueness in exploration of self, others, and the world through the use of narratives and aphorisms,22–27 reflective writing,28–30 discussions,5,21,31 literature,21,32,33 film,34 theater,35–38 and art39,40 in order to enhance one’s understanding of the human dimensions of illness and health and healing. The emphasis here is to engage in reflective interactions (with a patient; with a text; with a play, film, or essay; with each other), in opportunities to grapple with moments of uncertainty and discomfort,5,29,41 and to go ultimately beyond discussions to action in the world.
Assessment or Other Places to Look for the Wallet
There’s a joke in which a traveler runs across an old man who is searching for something beneath a street lamp late at night. “What are you doing?” the traveler asks. “I lost my wallet,” replies the old man. The traveler gets down on his hands and knees and begins to help in the search. “Why do you think that you lost it around here?” asks the traveler. “I have no idea where I lost it,” replies the old man. “It’s just that the light is better around here.”
One wonders whether the way we assess medical students in areas of social relevance is something like the old man’s search for his wallet. One wonders whether, out of enthusiasm to develop an “objective,” standardized, and reproducible way of defining and implementing competencies and assessing outcomes, one ends up missing exactly what one is trying to teach. One also wonders if an overreliance on competencies as the means to assess student progress threatens to reduce the profound, complex human values and interactions inherent in the act of healing into overly simplified checklists of modular sets of skills and stereotyped, fragmented behaviors robbed of context and reproduced in standardized settings. Competency-based assessment of knowledge, skills, and attitudes in these areas may provide simple metrics by which one can talk about “progress”; however, is this approach accurate? Indeed, is it authentic? That is, does it truly document the evolution of a learner into a professional being-in-the-world?
The task here is twofold: to eschew overly simplistic formulations on the one hand and attempts to ignore the problem on the other. One must confront the challenge of assessment in these areas head-on but do so in a way that preserves the sense of continuity, context, complexity, autonomy, and individuality that characterizes such development. Such assessment should be reflective and dialogical and use thoughtful, in-depth explorations of student-created products of learning, such as reflective essays,28,30 creative writing,42,43 and electronic portfolios,44–47 as part of ongoing conversations and interactions between learners and trusted role models/mentors/instructors. The creation of art by learners40,48,49 may be a particularly powerful means to assess this type of learning because it may tap into unconscious, tacit beliefs and insights in ways that otherwise may not be easily accessible.40 Admittedly, this approach does not fit easily into a standardized template or reproducible scheme: documenting professional and personal growth and understanding is hugely difficult, time-consuming, and labor-intensive. It may be something for which medical schools currently don’t have the personnel or the resources. Also, it seems so … subjective. It may be easier to look for things where the light of attention conveniently shines; nonetheless, it is much more challenging—but more authentic—to peer into the shadows to see where true understanding lies.
Beyond Competencies: Toward Transformative Medical Education
If one is to go beyond fulfilling and assessing externally imposed, often narrowly defined competencies, what are the ultimate goals of educational efforts in socially relevant areas of medicine? A principal educational goal of this type of learning is the enhancement of an understanding of the social role of the physician. Here, “understanding,” is meant to connote more than cognitive comprehension: It is a deep and abiding personal engagement with medicine as a social and moral activity. Unlike competencies, understanding arises from an ongoing process: an interplay between one’s internal self and others in the world, its direction is internally derived, and its sources run deep—and dwell within—the individual’s sense of self and worldview. So what is the role of the educator in enhancing this understanding? Barnett,1 following Polanyi, asserts that the role of the teacher is to help students to become aware of the understanding that they possess but of which they are not aware. In this sense, the teacher calls on her or his own background, values, and life experiences and becomes a guide for the student in a process of discovery and in a journey toward a professional self that is not fully known.
So, one might ask, what is the ultimate developmental goal? What does this professional look like? I would agree with a number of different writers50–54 that this individual should aspire to embody Aristotelian phronesis (practical wisdom) in which a physician sees her- or himself as a moral being-in-the-world who acts justly for the benefit of the self and of humankind. Aristotle55 distinguishes phronesis from other ways of knowing, including epistēmē (theoretical knowledge) and technē (technical knowledge or skill) and asserts that phronesis involves an individual’s moral actions among other individuals in the world. It is “a true and reasoned state of capacity to act with regard to the things that are good or bad for man.”55(BookVI.5.1145) This type of living is embodied reflection: It is the continual shifting of one’s gaze from internal values, motivations, and perspectives outward into the world. Also, unlike epistēmē, which is concerned with contemplation of knowledge for its own sake, phronesis is oriented ultimately to action. The individual who engages in phronesis “will be of necessity acting and acting well.”55(Book I.8.1099)
In the context of medical education and clinical practice, the concept of phronesis fits well into the proposed approach. As described by Pellegrino and Thomasma,50(pp18–30) phronesis is an example of “virtue-based ethics,” which emphasizes cultivation of a character and “habitual disposition” to act morally, in contrast to “duty-based” or “principle-based ethics,” which involves adherence to specific universal principles or externally proscribed actions. Furthermore, phronesis is not a specific skill (technē) to be considered separately from its expression in action but is only realized in “close-to-the-ground” practices54 in specific situations and contexts.51,52,54 That is, the teaching and learning of practical wisdom arises through reflection and discourse about specific life contexts and situations, such as at the end of life or in the aftermath of medical error,56 rather than in the memorization of specific professional attributes or fulfillment of specific educational competencies. When applied to doctoring, the idea of phronesis links the knowledge and skills of the biomedical and clinical sciences with a moral orientation and action that addresses human needs and interests in the practice of medicine.
Finally, the concept of the development of a professional who acts with practical wisdom in the world also involves a paradigmatic shift. Discussions of the “hidden curriculum” always seem to imply that the impact of the environment on learners is unidirectional: Learners are passively subjected to the negative influences of the hidden curriculum that pervade the clinical environment. Even notions of moral resilience or “resistance”57 arise from this view; that is, one must use one’s own inner resources to fight against the dehumanizing influences of the clinical environment. The problem with this view is that it ignores the learners’ impact on, and shaping of, this very environment and culture. In contrast, an orientation toward phronesis implies agency: It involves the idea of an actor-in-the-world, oriented toward acting rightly in affirmation of human needs and values.58
In summary, there is a fundamentally different epistemology involved in the areas of medicine of social and societal relevance. Learning in these areas consists not of a passive acquisition of a specific body of knowledge or set of skills but, rather, of a reflective orientation to, and understanding of, the self (both professional and personal), others, and the world. This epistemological difference calls for approaches to teaching, learning, and assessment that are different from the competency-based paradigms in wide use and instead should aim for the development of a kind of practical wisdom or phronesis as the primary educational goal in education in areas of social significance. Ultimately, this approaches shifts the educational locus of control from externally imposed standards to individual agency and to the actualization of individual possibilities of becoming moral beings-in-the-world.59 This is the ultimate emancipatory consequence of medical education for social responsibility.
Acknowledgments: The author would like to thank the University of Michigan Center for Research in Learning and Teaching for its generous support, as well as the students, volunteers, faculty, and staff of the Family Centered Experience and Longitudinal Case Studies programs for their commitment to teaching and learning.
* In his later works, such as The Theory of Communicative Action (1984) and Moral Consciousness and Communicative Action (1990), Habermas chose to elaborate on communicative interests and knowledge as the basis of a general theory of society without expanding on his theories of emancipatory interest and critical knowledge. His original conceptualization of instrumental, communicative, and emancipatory interests and their respective types of knowledge is, however, most helpful to our discussion here.
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