the good doctor in medical education 1910-2010
DESCRIPTION
Presentation by Cynthia Whitehead in KMD1001, October 1, 2012TRANSCRIPT
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?