1. From Flexner to the Future: Recommendations of the Carnegie Reports 1910 and 2010 David M. Irby, PhD NCNMLG/MLGSCA Meeting February 25, 2011

2. The Carnegie Team No financial relationships to disclose

3. Reforming Medical Education -1910- -2010-

4. 1910: Flexners Observations Great variability Lax admissions standards Passive learning, anemic curricula, poor facilities Faculty of practitioners No accreditation, certification or residency training Flexner. Medical Education in the United States and Canada (1910).

5. Flexners Findings in Bay Area University of California Stanford Jr Univ SOM & Cooper Medical College College of Physicians & Surgeons Hahnemann Med College of the Pacific College of Medicine & Surgery

6. Flexners Recommendations High standards for admission –College degree with science requirements Expanded science-based curriculum –Two years basic sciences –Two years clinical experience University/teaching hospital

7. Medical Education Then & Now -1910--2010-

8. 2010 Carnegie Study Part of 5 profession study Included 14 site visits Based on research in the learning sciences and medical education *Winner of the 2010 Prose Award for Education from the Association of American Publishers

9. Recommendations for the Future Habits of inquiry and improvement –Focus on excellence Integration –Connect knowledge and experience Standardization and individualization –Set outcomes and allow flexibility in learning Identity formation –Develop professional values and dispositions

10. Habits of Inquiry & Improvement Develop habits of learning and innovation –Develop routine and adaptive expertise –Achieve information literacy Advance expertise through deliberate practice & feedback Participate in communities of inquiry and practice

11. PubMed Articles about Librarians involved in Medical Education Publication year Number of Publications Josephine Tan - UCSF

13. Inquiry & Improvement How can we improve our transitions of care?

14. Everyday Inquiry/Improvement Access information, identify best practices and critically appraise the literature Engage in QI projects, with training and support Document and assess project-based learning

15. Recommendations for the Future Habits of inquiry and improvement –Focus on excellence Integration –Connect knowledge and experience Standardization and individualization –Set outcomes and allow flexibility in learning Identity formation –Develop professional values and dispositions

16. Integration Connect knowledge and experience Engage in multiple forms of reasoning –Analytical reasoning –Pattern recognition –Creative and adaptive reasoning Access information and integrate into action

17. Examples of Integration Early clinical immersion Longitudinal integrated experience Knowledge management and information literacy

18. Recommendations for the Future Habits of inquiry and improvement –Focus on excellence Integration –Connect knowledge and experience Standardization and individualization –Set outcomes and allow flexibility in learning Identity formation –Develop professional values and dispositions

19. Standardize on Outcomes Standardize on learning and practice outcomes Develop competencies and milestones Use multiple forms of assessment

20. Competency Frameworks

21. ACGMECanMEDSTomorrows Doctor - UK Good Doctor - Sweden Medical knowledge Medical expertScientistMedical science Patient carePractitioner Interpersonal and communication skills Communicator Collaborator Communication Practice based learning Manager Systems based practice Health advocateQuality development ProfessionalismProfessional Scholar

22. Standardization and Milestones Caverzagie KJ, Aagard EM, Chick DA, Smith CD. Measuring resident progress: Competency milestones in internal medicine. Academic Internal Medicine Insight. 2010;8(1):4-5.

23. Linear Individualization: Core & Depth R-3: General Medicine or Subspecialty Focus R-2: Core + Boards Additional Subspecialty Training R-1: Core Internship Internal Medicine Residency Program -Depth- - Core-

24. Recommendations for the Future Habits of inquiry and improvement –Focus on excellence Integration –Connect knowledge and experience Standardization and individualization –Set outcomes and allow flexibility in learning Identity formation –Develop professional values and dispositions

25. Professional Identity Formation Formation –Process of taking on identity –Commitment to values, dispositions and aspirations Learned through –Participation in a community of practice –Observation of role models, interactions –Coaching, instruction, assessment and feedback

26. Strategies for Formation Courses, rituals, and codes of conduct Self-assessment, reflection, planning Appreciative inquiry Ratings of respect Institutional Culture

27. Summary 1.Inquire and improve 2.Integrate 3.Individualize and standardize 4.Identity formation

28. References Cooke M, Irby D, Sullivan W, Ludmerer K. American Medical Education One Hundred Years After the Flexner Report. NEJM. 355:1339-1344, 2006. Cooke M, Irby DM, OBrien BC. Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco: Jossey-Bass, 2010. Irby DM, Cooke M, OBrien B. Calls for Reform of Medical Education by The Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 85(2):220-227, 2010.