10.4 Conclusions and Caveats

Guided and constrained by international accreditation standards, medical education is inherently conservative.  It is also restless, every hurrying to integrate new research findings to practice and use emerging evidence to inform pedagogy. Medical schools in Canada are accountable to societal needs, and while fine-tuning their programmes in small ways for each new class they also keep one anxious eye on the horizon to anticipate what might come next and remain nimble to adjust course for the unexpected.

Though Mr. Flexner could not have anticipated these changes in medical education, they have been predictable in their direction toward teaching in the real context of care delivery to train students to become physicians skilled—not just in acquiring information, but also in making Connections and seeing Extensions, to imagine new ways of working and solutions to old and new problems. The unique skills gained through a medical education are the abilities to form Connections and apply information in novel contexts, to make Extensions.

In medical education, we are shifting our focus from approaches that value learning large masses of information to one where we seek to create student experiences based in patient care and richly interconnected with other learning experiences; an experiential education to attain professional competence by becoming an active and legitimate member of communities of practice with ongoing learning relationships with patients, preceptors, and communities. By learning in a complex reality we show students that learning deepens over time and is stabilized by Connections and cross-linkages.  We are offering an education not measured by ICE but infused with it. When we educate students to see Connections between their various experiences and domains of learning, when we articulate relationships and connect skills in novel ways then they will bring these skills to their practice, it will encourage them to extrapolate what they know to novel situations with confidence in their ability to anticipate and plan for varied outcomes.

ICE frames learning as filled with potential, as constructed webs of understanding, ICE is a language of possibility. ICE acknowledges that learning is not linear that it is iterative and messy, a student must learn and relearn the basics as new evidence emerges and as other learning sheds new light on old certainty. By learning in this way students become familiar with the whole territory of learning, the rich cartography of an academic domain. This is the true realization of Extensions—the learner becomes a practitioner who can move freely across the landscape of their discipline and demonstrate new Connections and Extensions to expansive possibilities.

Both ICE and medicine are inherently constructivist, both employ an approach to learning based on growth and understanding networks. Medical learners and physicians develop competence through the experience of making Connections and demonstrate expertise when they extend what is known when they can entertain a novel possibility, see new patterns and possibilities. As we educate medical students and design educational experiences with the goal of Extensions in mind, we see that medical education is aligned with, and well served by, the ICE framework.

When viewed through the lens of ICE, we can view changes to medical education, within the consistent Flexnerian structure, as a move toward pedagogies that support Ideas, Connections, and Extensions as the fertile landscape for professional education and lifelong learning. We can see that changes in medical education have moved toward: the application of Ideas in real-world situations and engagement with real problems, learning how to learn, basing action in evidence and experience, seeing the Connections and integration of knowledge and action, and positioning students to use formal education as the beginning of limitless learning.

Though medicine is slow to change and can feel plodding in development, it is also in the business of possibility and future-oriented toward limitless learning. Changes in medical education in the century since Flexner’s report have been more inclusive of these elements, medical education has evolved in ways that ensure a common knowledge base of Ideas and content, with increasing value placed on early opportunities to see the Connections between areas of learning and a desire to situate students for success as physicians adept at making Extensions. The history and structure of medical education align with the elements of the ICE model and at each turn of the cycle of pedagogical development in medical education we see changes that make space for the full realization of the ICE philosophy. Like a plant growing in the direction of the sun, medical education since Flexner has made growth in the direction of Connections and Extensions—toward the philosophy of ICE.

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