The good doctor in medical education 1910-2010

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Presentation by Cynthia Whitehead in KMD1001, October 1, 2012

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The good doctor in medical education 1910-2010

  1. 1. THE GOOD DOCTOR INMEDICAL EDUCATION1910-2010Cynthia Whitehead MD, PhD1 October 2012
  2. 2. COMPETENCYAs a series of Roles depicted in the image of a daisy
  3. 3. DATA SETEducating Future Physicians for Ontario (EFPO) archivesThomas Fisher Rare Books Library, University of Toronto
  4. 4. Results“[EFPO had its] genesis following the 1986 Ontario physicians’ strike which revealed a gap between the Ontario medical profession and the public…. [EFPO will] bridge the gap…” Seidelman, EFPO archives 1992
  5. 5. “[EFPO began because of] concern thatthe relationship between the medicalprofession and the Ontario public wasshowing signs of stress” Neufeld et al CMAJ, 1993
  6. 6. DISCOURSES OF THREAT“Legal issues, new patterns of reportingresponsibility and more vocal, betterinformed patients often left physicians with asense of being threatened from unknownsources.” EFPO Working Paper 3, p 5
  7. 7. “[Physicians expressed] frustration over theways in which forces other than thoserelated to patient health and clinicalperformance could alter the practice ofmedicine.” EFPO Working Paper 3, p 11
  8. 8. “Conflict and tension were described as acharacteristic of the way that many of thesephysicians related to their environment.” EFPO Working Paper 3, p 11
  9. 9. ROLES AS SOLUTION“[Goal of EFPO is] to define the future roles of physicians in Ontario in relation to community health needs” Neufeld & Sellers, EFPO archives, 1988
  10. 10. THE SOCIAL CONSTRUCTION OF ROLES
  11. 11. “IMPLICIT IDEALS”The health and illness expertThe health care resource consultantThe health care system advocateThe patient educator/enablerThe “humanist”
  12. 12. EFPO ROLESMedical expert, clinical decision makerCommunicator, educator, humanist, healerCollaboratorGatekeeper, resource managerLearnerScientist, scholarHealth advocatePerson
  13. 13. NATURE OF ROLES?“The roles provide a framework which is helpful in identifying key issues related to clinical problems . . .” EFPO consensus summary 1992
  14. 14. PERCEPTION?“ . . . however, the “roles” are a publicperception, not necessarily an ideal [andthe] “roles” are not necessarily of equalimportance.” EFPO consensus summary 1992
  15. 15. ARCHETYPE?“ [Roles] reflect the many needs andexpectations of Ontario society and outlinean archetype of the ideal physician.” Maudsley et al Acad Med, 2000
  16. 16. ANALYSISRoles were proposed as solution (not emergent from) EFPO processSocial construction of roles was contentious and negotiatedRoles development occurred in specific historical context, influenced by discourses of the time
  17. 17. “If many medical procedures do not have scientific justification, as is now claimed, the state can sponsor ‘medical’ or non- medical experts to determine the ‘scientific’ basis of medical practice itself. A major underpinning of medical power, its scientific basis, is being undercut.” Coburn, 1997
  18. 18. There was a defensive component to roles developmentProfessional competence is context-bound and socially negotiated
  19. 19. Competency frameworks are not objective idealsConstruction of any working model of health professional will be affected by economic, social and political factors that shape health systems
  20. 20. FLOWER POWER?How did we get here?
  21. 21. How have the discourses of the good doctor in medical education changed in the past century?What are the implications and consequences of these shifts?
  22. 22. METHODOLOGYFOUCAULDIAN critical discourse analysis of roles development
  23. 23. METHODOLOGY LANGUAGE is socially constructed
  24. 24. LANGUAGE Practices / Power
  25. 25. Regimes ofTruth
  26. 26. How far back to look?Truth universally acknowledged that modern medical education began with Abraham Flexner’s 1910 Report on Medical Education in the United States and Canada
  27. 27. RESULTSSeries of discursive shifts in conception ofthe good doctor from the FlexnerianScientist to the CanMEDS Roles
  28. 28. UNEXPECTED DISCURSIVE SHIFT#1Post-Flexner: – Scientist vanished (science became curricular content—the ‘stuff’ or ‘stuffing’) – Character continued
  29. 29. UNEXPECTED DISCURSIVE SHIFT#2Late 1950’s: – Characteristics emerged – Character vanished
  30. 30. SCIENTIST to CHARACTER
  31. 31. SCIENTIST The scientific inquirer assembles facts from every available source and by every possible means. Science resides in the intellect, not in the instrument. (Flexner 1925)
  32. 32. CHARACTERModern medicinecannot be imparted toeveryone; it can beimparted to the bestadvantage only topersons of goodcharacter, fixedpurpose, good nativeintelligence, trained toserious application van Beuren, 1929
  33. 33. CHARACTERISTICS to COMPETENCE (ROLES)
  34. 34. CHARACTERISTICS [We must] identify the relevant intellectual and nonintellectual characteristics that can be measured—then we can proceed with some confidence in applying the findings to the problems of medical education in filling society’s need for medical service Gee 1957
  35. 35. COMPETENCE (ROLES)Outcomes based education:a performance-based approachat the cutting edge ofcurriculum development, [which]offers a powerful and appealingway of reforming and managingmedical education. Theemphasis is on the product—what sort of doctor will beproduced—rather than on theeducational process. Harden 1999
  36. 36. IMPLICATIONSWho is a good doctor?What is a good doctor?What does a good doctor know?

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