Flourishing extends as far as understanding, and those who truly understand more truly flourish, not as a mere accident but through the excellence of their understanding.

Aristotle, Nicomachean Ethics

In perhaps the finest work of philosophical moral philosophy ever produced, the Nicomachean Ethics, Aristotle develops an account of the good for human beings grounded in the idea of human flourishing. If we are to flourish as human beings, he suggests, it is vital that we determine the ends most worth dedicating our lives to, and then do our utmost to excel at the activities they call for. To flourish as a human being is to do the humanly most important things well, to excel at them.

The same might be said for the field of medical education. To excel as educators, we need to determine what medical education is about, define those educational activities that are most essential to the flourishing of our learners and faculty members, and identify approaches that will enable us to excel at those activities.

Since the days of the Hippocratic Oath, passing on to the next generation what we have learned about medicine has been recognized as one of our primary missions. Yet this mission is threatened by many forces at work in contemporary healthcare. These include institutional, economic, and societal forces that raise doubts about the very nature and purposes of medicine. By implication, they also call into question the proper relationship between doctors and patients, and offer competing visions of what physicians most need to know.

Physicians in training represent the future of medicine. Because physicians wield great influence in health decision making, they also represent the future of healthcare in the United States. How we educate them will powerfully shape the care provided not only our own generation, but also our children and our children's children.

Approximately 67,000 students are enrolled in the 125 US allopathic medical schools, with a roughly proportionate number in the 20 accredited schools of osteopathic medicine. Over 100,000 additional physicians are enrolled in accredited US postgraduate training programs as interns, residents, and fellows. Both numbers are exceeded by the number of full-time medical school faculty members, which now stands at approximately 120,000.

This book is about the pursuit of excellence in medical education, construed above all in ethical terms. It does not purport to offer a fully comprehensive account of this vast terrain, but aims instead to provoke exploration and discussion. One-size-fits-all educational approaches are doomed to fail. Only approaches tailor made to our distinctive opportunities and resources will suffice. My fondest hope is that these essays will serve as useful points of departure for lively discussion and innovation among dedicated learners and educators.

The first chapter explores the variable status of education as a mission of US schools of medicine. Though we call ourselves schools, we have not always organized and conducted ourselves as though education were our first priority. In education as in life, it is difficult to excel at something that we do not see as a central mission. Serious effort will be needed to restore education to its proper place at the center of our collective field of view.

One of the key ways to reinvigorate medical education is to begin to think of our learners as teachers in their own right, and to create opportunities for them to shine as educators. Furthermore, we need to structure academic medicine so that it attracts the very best and brightest medical students and residents into academic careers. We need to begin now to cultivate the excellence of the next generation of medical educators.

The second chapter emphasizes the need for medical educators to look beyond the bounds of medicine for insights on educational excellence. Physicians often do not know everything we need to know to excel at our craft. Research in the field of education has shed considerable light on the work of medical educators, including how we learn, the nature of expertise, and the workings of the human memory.

How can we be prepared to teach effectively until we grasp deeply what it means to learn? Are we aiming to educate physicians who are merely competent, or physicians who excel at their missions of patient care, research, and education? With each reading, lecture, and discussion, what are we hoping learners will retain, and how can we enhance useful knowledge and skills? How can a deeper understanding of health and disease enhance our efforts to promote human welfare?

The third chapter focuses more directly on the characteristics of medicine's learners. When we think of an exemplary learner, what images come to mind? What distinguishes medical students, residents, fellows and practicing physicians who merely get by from those who truly shine? If our learners do not see the target they are trying to hit, they are more likely to miss it.

What can learners' visions teach us about the challenges and opportunities before contemporary medical education? What is the relationship between our educational programs and the healthcare needs of our institutions, communities, and society? Where are the greatest gaps, and what can we do to encourage learners to consider careers in the most underserved areas?

Learning excellence is the focus of the fourth chapter. In thinking about our vision of the ideal learner, we need to look beyond the stellar student who aces all the tests. Some day, our learners will run out of tests to study for. Then what learning objectives will guide and inspire them? We need to encourage the physicians of tomorrow to assume more responsibility for their own learning today.

There is no mandate that a faculty member must be the star of every class. We can strengthen our learners by sharing more responsibility with them. What does it mean to understand a disease, a therapy, or a patient, and how can we partner with learners to foster multi-dimensional inquiry at deeper levels of understanding? There is no need to dispense with testing, but we need to reexamine the understanding our evaluation systems promote.

The fifth chapter explores the characteristics of great medical educators. One is an infectious dedication to inquiry that draws students into learning and investigation. We need to understand medical cognition in more nuanced terms than a simple dichotomy between right and wrong. It is possible to be right yet irrelevant and uninspiring,while many of our most important insights spring from mistakes. If learners depart from us merely aspiring to avoid error, then we have done them a disservice.

Getting things right is less a matter of knowing the right answer than doing the appropriate thing. In this respect, emulation is king. As educators, we need to serve as good role models for those learning this art. We need to look beyond sorting the good from the bad, and instead focus on helping learners perform at their best. Our appraisals should be fair and accurate, but they must also promote improvement.

Technique, which is playing a growing role in medical education, is the focus of the sixth chapter. Technology can open up new opportunities, making education more effective, more efficient, and more widely accessible. However, we must guard against any naive presumption that learner knowledge, skills, and character necessarily improve with every technological investment.

Technology can expand our reach, but it cannot do the reaching for us. We need to distinguish between the transmission of information and the development of understanding. We can change the vehicle that delivers our groceries without necessarily improving the nutritional quality of our diet. So, too, we can change the technology of learning without necessarily elevating understanding. Merely throwing more information at learners may in fact undermine it.

The seventh chapter deals with obstacles to excellence. What outcomes or performance indicators are we assessing in medical education? What aspects of the work of educators and learners do those indicators tend to illuminate, and which do they tend to obscure? What kind of future are they promoting, and what opportunities are they tending to forego?

What is the medical school's appropriate role in reflecting or advancing the diversity of our broader society? Should the medical profession mirror the sexual, racial, and ethnic diversity of our society, or should considerations of merit alone determine our admissions and hiring policies? Are physicians paid fairly, and to what degree should we attempt to use compensation to steer students and faculty members toward careers they might not otherwise pursue?

The eighth chapter turns to fostering excellence in educational programs. We need to think carefully about the development of our colleagues and the institutions in which we work. What psychological factors regulate the pursuit of excellence? What perspectives and attitudes distinguish educators, learners, and administrators who perform well from those who never reach their full potential? Are we treating our colleagues with the respect and trust they need to perform at their best?

Our very notion of good work is at stake. What features distinguish the work of the people we most admire, and what steps could we take to emulate their excellence? What can we do to enhance professional dedication and fulfillment? The role of ethics deserves more attention than it commonly receives. Ethics is not just about right and wrong. It is first and foremost about excelling as physicians and human beings.

Medicine's role as a center of excellence in higher education is the focus of the ninth chapter. For too long, we have tolerated increasing fragmentation, and medical school faculties have acted as though we were separate from universities. We need to foster creative interactions, first within the medical school, and second between the medical school and the larger intellectual community of which it is a part.

Medicine is an inherently interdisciplinary enterprise. To achieve its missions, it needs to work with other disciplines and communities. We need to make the medical school home to the most fruitful conversation on campus, the exemplary site of knowledge sharing in higher education. We need to foster participatory leadership throughout medical education. We need to recruit and retain leaders with these ends in mind.

The tenth chapter explores the development of leaders in medical education. Medical education can be only as good as the people who lead it. How much of the current medical school and residency curricula are focused on the development of leadership potential? This should be one of the core talents we seek to develop in every medical student, resident, fellow, and faculty member.

Molecular biology, anatomy, diagnosis, and therapeutics are not enough to excel as a physician. We also need to understand the institutional and cultural contexts of healthcare, and how to work through organizations. We need to understand not only human biology but human psychology. Leadership plays a vital role in enabling our educational programs to pursue their missions.

With each generation, we need to rekindle the perennial conversation among those who care about the future of medicine and the patients and communities we serve. Socrates said that the unexam-ined life is hardly worth living. Likewise, medical education can achieve its potential only if we reflect carefully on it. It is my hope that this book will help spark that conversation.

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