the good doctor in medical education 1910-2010

Cynthia Whitehead MD, PhD

1 October 2012

THE GOOD DOCTOR IN MEDICAL EDUCATION 1910-2010

COMPETENCY

As a series of Roles depicted in the image of a daisy

DATA SET

Educating Future Physicians for Ontario (EFPO) archives

Thomas Fisher Rare Books Library, University of Toronto

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

“[EFPO began because of] concern that the relationship between the medical profession and the Ontario public was showing signs of stress”

Neufeld et al CMAJ, 1993

EFPO Working Paper 3, p 5

DISCOURSES OF THREAT

“Legal issues, new patterns of reporting responsibility and more vocal, better informed patients often left physicians with a sense of being threatened from unknown sources.”

“[Physicians expressed] frustration over the ways in which forces other than those related to patient health and clinical performance could alter the practice of medicine.”

EFPO Working Paper 3, p 11

EFPO Working Paper 3, p 11

“Conflict and tension were described as a characteristic of the way that many of these physicians related to their environment.”

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

THE SOCIAL CONSTRUCTION OF ROLES

“IMPLICIT IDEALS”

The health and illness expert

The health care resource consultant

The health care system advocate

The patient educator/enabler

The “humanist”

EFPO ROLES

Medical expert, clinical decision maker

Communicator, educator, humanist, healer

Collaborator

Gatekeeper, resource manager

Learner

Scientist, scholar

Health advocate

Person

NATURE OF ROLES?

“The roles provide a framework which is helpful in identifying key issues related to clinical problems . . .”

EFPO consensus summary 1992

PERCEPTION?

“ . . . however, the “roles” are a public perception, not necessarily an ideal [and the] “roles” are not necessarily of equal importance.”

EFPO consensus summary 1992

ARCHETYPE?

“ [Roles] reflect the many needs and expectations of Ontario society and outline an archetype of the ideal physician.”

Maudsley et al Acad Med, 2000

ANALYSIS

Roles were proposed as solution (not emergent from) EFPO process

Social construction of roles was contentious and negotiated

Roles development occurred in specific historical context, influenced by discourses of the time

Coburn, 1997

“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.”

There was a defensive component to roles development

Professional competence is context-bound and socially negotiated

Competency frameworks are not objective ideals

Construction of any working model of health professional will be affected by economic, social and political factors that shape health systems

FLOWER POWER?

How did we get here?

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?

METHODOLOGY

FOUCAULDIAN

critical discourse analysis of roles development

LANGUAGE

is socially constructed

METHODOLOGY

LANGUAGE

Practices / Power

Regimes of

Truth

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

RESULTS

Series of discursive shifts in conception of the good doctor from the Flexnerian Scientist to the CanMEDS Roles

UNEXPECTED DISCURSIVE SHIFT # 1

Post-Flexner:

– Scientist vanished (science became curricular content—the ‘stuff’ or ‘stuffing’)

– Character continued

UNEXPECTED DISCURSIVE SHIFT # 2

Late 1950’s:

– Characteristics emerged

– Character vanished

SCIENTIST to CHARACTER

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)

CHARACTER

Modern medicine cannot be imparted to everyone; it can be imparted to the best advantage only to persons of good character, fixed purpose, good native intelligence, trained to serious application van Beuren, 1929

CHARACTERISTICS to COMPETENCE (ROLES)

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

COMPETENCE (ROLES)

Outcomes based education:a performance-based approach at the cutting edge of curriculum development, [which] offers a powerful and appealing way of reforming and managing medical education. The emphasis is on the product—what sort of doctor will be produced—rather than on the educational process.

Harden 1999

IMPLICATIONS

Who is a good doctor?

What is a good doctor?

What does a good doctor know?