Carnegie Foundation and Abraham Flexner

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  • Dr. Sam Caldwell is a 38-year-old general surgeon called to the emergency department in anticipation of the arrival of a woman gravely injured in an automobile accident. Initially trapped in her car, she is extricated using the “Jaws of Life”. At the scene, the paramedics describe a moaning woman who appears to be in her mid-twenties with crush injuries to her torso, particularly her pelvis. By the time she is ready for the ten-minute transport to the hospital, she has developed signs of shock.
    One of the things that Dr. Caldwell enjoys about trauma surgery is that each patient’s injuries are unique. Providing expert care requires the on-the-spot integration of what he knows of the field, both the formal knowledge and the experience he acquired over his residency and the five years he has been in practice, with the particulars of each patient’s situation. As he hurries to the emergency department, he anticipates what this woman’s care is likely to require of him immediately: the ability to lead the emergency department team, nurses, respiratory therapists, X-ray technicians and others, in the patient’s initial assessment and stabilization; surgical skills to address traumatic injuries within his expertise and the recruitment of other specialists to manage her orthopedic and urologic injuries, and the capacity to establish a connection and communicate effectively with a distraught family. Assuming that she survives the night, he will need to work with his hospital’s intensivist and the highly skilled nurses in the ICU, to participate in the hospital’s campaign to reduce ventilator-associated pneumonias and to bring in a physical therapist, and possibly a physiatrist, when his patient is ready. Dr. Caldwell’s hospital is near a major highway and he briefly reflects on the number of alcohol-related accidents they see. He has been active in his community’s schools talking about injury prevention in general and underage drinking and driving in particular. As he is wondering if he might be more effective at the community level, the paramedics race in with his patient. He asks for two large IV’s and begins the trauma assessment.
  • Medical school is lock step - there is no recognition of students’ prior preparation and experience
    All learners d the same thing - little opportunity to express interests and talenst
    Residency time-and-process metrics
  • Dr. Sam Caldwell is a 38-year-old general surgeon called to the emergency department in anticipation of the arrival of a woman gravely injured in an automobile accident. Initially trapped in her car, she is extricated using the “Jaws of Life”. At the scene, the paramedics describe a moaning woman who appears to be in her mid-twenties with crush injuries to her torso, particularly her pelvis. By the time she is ready for the ten-minute transport to the hospital, she has developed signs of shock.
    One of the things that Dr. Caldwell enjoys about trauma surgery is that each patient’s injuries are unique. Providing expert care requires the on-the-spot integration of what he knows of the field, both the formal knowledge and the experience he acquired over his residency and the five years he has been in practice, with the particulars of each patient’s situation. As he hurries to the emergency department, he anticipates what this woman’s care is likely to require of him immediately: the ability to lead the emergency department team, nurses, respiratory therapists, X-ray technicians and others, in the patient’s initial assessment and stabilization; surgical skills to address traumatic injuries within his expertise and the recruitment of other specialists to manage her orthopedic and urologic injuries, and the capacity to establish a connection and communicate effectively with a distraught family. Assuming that she survives the night, he will need to work with his hospital’s intensivist and the highly skilled nurses in the ICU, to participate in the hospital’s campaign to reduce ventilator-associated pneumonias and to bring in a physical therapist, and possibly a physiatrist, when his patient is ready. Dr. Caldwell’s hospital is near a major highway and he briefly reflects on the number of alcohol-related accidents they see. He has been active in his community’s schools talking about injury prevention in general and underage drinking and driving in particular. As he is wondering if he might be more effective at the community level, the paramedics race in with his patient. He asks for two large IV’s and begins the trauma assessment.
  • Let me end by acknowledging my colleagues and showing you how we listened to many focus groups of learners for our study.
  • Carnegie Foundation and Abraham Flexner

    1. 1. Mission: To prepare physicians who are relentlessly curious, who are determined in their efforts to improve patient outcomes, and who apply their knowledge and skill with judgment and compassion
    2. 2. The Four I’s of The Carnegie Foundation ‘Preparation for the Professions’ Program: Implications for Humanistic Medicine Molly Cooke MD Senior Scholar, CFAT Director, Haile T. Debas Academy of Medical Educators Professor of Medicine, UCSF
    3. 3. The Four I’s of the Medicine PPP Individualization Integration Insistence on Excellence Formation of Professional Identity
    4. 4. Why individualize? • Respect learners’ previous experience and goals • Increase educational efficiency • Expand breadth of learner mastery
    5. 5. From Process-Based to Outcome-Based Process Outcome Driving force for curriculum Content – Exposure to important K, S, A Outcome – Ability to perform at given level Program Completion Fixed Time Variable Time Assessment Tools Knowledge Proxies Authentic Tasks Carracio et al. Shifting Paradigms: From Flexner to Competencies. Academic Medicine 2002, 77:361-367.
    6. 6. Competency-based assessment and the duration of residency training Procedure Traditional training (mo.) Competency- based training (mo.) Lumbar laminectomy Closure 6-9 3-6 Laminectomy 24-36 18 Ant. cervical fusion - exposure 9-12 6 Pterional craniotomy 36-39 18 Suboccipital craniotomy 36-39 18 Long 2000 Acad Med
    7. 7. Competency-based assessment and the duration of residency training Procedure Traditional training (mo.) Competency- based training (mo.) Lumbar laminectomy Closure 6-9 3-6 Laminectomy 24-36 18 Ant. cervical fusion - exposure 9-12 6 Pterional craniotomy 36-39 18 Suboccipital craniotomy 36-39 18 Long 2000 Acad Med
    8. 8. 3 Forms of Integration Multiple Roles of Physicians Holistic Perspective on Patients & Patient Care Formal & Experiential Learning
    9. 9. Integration of the roles of a physician Gruen 2004 JAMA • Physician-citizen, scientist, leader- manager, policy maker-advocate • Areas of concentration and Pathways
    10. 10. General Patient Care in an Integrated Model • AB: 63 year old established patient in my practice w/ remote HD, ADPKD, renal failure on PD Events over year: incarcerated hernia in exp lap incision, new Dx NSC lung cancer Learning points: molecular basis of cyst formation, giving bad news, interpretation of isolated prolonged aPTT, cross-specialty collaboration • MM: 40 year old with spina bifida, chronic pain, depression, and poly- substance abuse referred from neurology in September for primary care Events over year: Doctor-shopping, suicide attempt, residential rehab Learning points: Embryology of neural tube defects, folate and methylation hypothesis, principles of pain management, pharmacology of buprenorphine, setting limits and managing boundaries
    11. 11. Modified from: http://e-archive.vanderbilt.edu/bitstream/1803/216/18/spiral+learning.doc Accessed 3/31/2008 Integration of Formal & Experiential •Formal Knowledge – facts, concepts, theories •Experiential Knowledge – performing tasks and activities in context •Integration through: -Guided Participation -Iterative Sequencing 6. Reflect on outcomes
    12. 12. The Four I’s of the Medicine PPP Individualization Integration Insistence on Excellence Formation of Professional Identity
    13. 13. Medical education in the Dreyfus model of skill acquisition 5-7 years in practice Novice Advanced beginner Competent Proficient Expert Medical school Batalden Health Affairs 2002 Experienced non- expert Expert Residency Early in practice Progressive reformulation Effortful reinvestment
    14. 14. Insistence on Excellence
    15. 15. The Four I’s of the Medicine PPP Individualization Integration Insistence on Excellence Formation of Professional Identity
    16. 16. Identity Formation • Formation – Process of becoming a physician and taking on identity – Commitment to values and dispositions of the profession • Learned through – Participation in a community of practice and adoption of professional behaviors, identity and values – Observation of role models and peer interactions – Coaching, instruction, assessment and feedback
    17. 17. Curricula and Humanism: Curriculum Content • “Doctoring” courses • Humanities courses, including ethics • Pathways-type opportunities • Presentation of science in an historical context
    18. 18. Curricula and Humanism: Curriculum Design • Individualized - Developmental - Learner-focused • Contextualized
    19. 19. Modified from: http://e-archive.vanderbilt.edu/bitstream/1803/216/18/spiral+learning.doc Accessed 3/31/2008 Pedagogies and Humanism • Active learning • Inquiry driven, with guidance • Dynamic interplay between formal and experiential knowledge-building 6. Reflect on outcomes
    20. 20. Assessment and Humanism • Multi-dimensional and multi-source • Emphasis on self- assessment • Aspirational framework
    21. 21. Curriculum Approaches to teaching and learning Assessment Institutional culture
    22. 22. Oath of Lasagna in 23 Languages 2008: Anatoly Urisman - Russian; Cindy Oparah - Ibo; Raymund Dantes - Tagalog; Nina Hansra - Punjab; Tim Joseph - Malayalam
    23. 23. Mission: To prepare physicians who are relentlessly curious, who are determined in their efforts to improve patient outcomes, and who apply their knowledge and skill with judgment and compassion
    24. 24. Carnegie Team Bill Sullivan PhD Molly Cooke MD David Irby PhD Lee Shulman PhD Anne Colby PhD Bridget O’Brien PhD http://www.carnegiefoundation.org/

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