Foreword by Alfred Tauber

Although this book might appear to be an essay on medical education, Richard Gunderman has actually written a moral treatise. In describing the sorry state of contemporary medicine and outlining a program for reform based on education, he would have the medical community reset its sights. Accordingly, he urges physicians to recast their narrow roles of healthcare providers and to become active moral agents engaged in a work of responsibility and self-reflection. "Responsibility" entails, in his discussion, the task of educating the next generation of doctors. Of course the care of the patient organizes his program, but he always remains focused on medical education. Not just an education to fulfill the technical and cognitive requirements of the discipline, but an education that pursues the much more ambitious goal of training physicians to fulfill the highest standards of care.

And "self-reflection" has been presented in the unusual pose of teaching. Again, the patient is the underlying moral object, but Gunderman is concerned more specifically with professional identity. Specifically, he recalls the old adage that when one teaches, one learns. The argument goes as follows. Because teaching commands an on-going self-reflection about competence and the necessary qualities of care that are being transmitted, the act of teaching itself becomes the lesson. And when the commitment to lifelong teaching as constitutive to professional identity is enacted, not only will the quality of practice improve, the moral standing of physicians will also be enhanced.

To achieve this comprehensive educational state, Gunderman admonishes, entreats, cajoles, requests, demands, and exhorts his readers to make teaching a central focus of professional life. And he would begin at the earliest opportunity, namely with medical students, who should internalize the ethical mandate to teach at the beginning of their education. Indeed, to learn and to teach are coupled in Gunderman's program in such a manner that this dialectic would be impressed upon the budding doctor as integral to her professional identity. If accepted at the onset, he hopes that a pattern of lifelong learning will be established, and more, that a particular kind of learning will be continued for the benefit of student and teacher.

And what that might be? The book points to many facets, but in the end, Gunderman settles on a basic dynamic between teacher and student that, for lack of a better characterization, I would call Socratic. Teaching and learning collapse into a dialogue, where the interlocutor (teacher) develops a student into a "philosopher," one, who himself for the "love of wisdom," will become a questioner/ teacher. Recall, Socrates never considered himself "wise," and always regarded his dialogues as an on-going educational process pointed towards his own improved sapientia.

This philosophical orientation remains hidden among the various values governing contemporary medicine. But we do well to recall Galen's observation, "The best physician is also a philosopher." Gunderman draws on that rich tradition and provocatively challenges us to enact an ethical medicine that makes teaching and learning integral to clinical practice. Dissatisfied with recertification as a measure of continuing education, Gunderman demands a higher standard, one drawn from its ancient sources: when clinical teaching assumes its basic form, the process of mastering the technical aspects of clinical medicine are linked to a deeper discourse, one that is based on the moral mandate to learn. And to learn, one must teach. In our own era, this fundamental moral injunction has been subordinated to other callings, mainly those in the service of an entrepreneurial ethic clothed in technology. By adopting this essentially humane course, Gunderman hopes that medicine itself will become more humane.

One wonders how this task might be accomplished beyond the theoretical outlines offered here. Gunderman repeatedly writes how "we" "should," or "must," or "need," to do pedagogical x and administrative y and professional z. But how to go from the conditional to the final process is not detailed. Indeed, our guide leaves much to be discussed. Perhaps that reticence is designed and calculated to make us devise the solutions that must be uniquely developed and applied. But beyond the institutional challenges, he leaves to each individual healthcare provider the responsibility (and opportunity) to teach the moral lessons at the heart of clinical care. So, by moving from lament to self-critical examination, Gunderman pushes the reader to rethink old assumptions about professional identity, competence, and self-fulfillment. In that task, Achieving Excellence in Medical Education ironically, and successfully, follows its own Socratic strategy! Indeed,Richard Gunderman has offered us a treatise well worth contemplating and embracing.

Zoltan Kohn Professor of Medicine Boston University

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