10.2 Discussion

In the early twentieth century medical schools in Canada and the United States were unregulated and highly divergent in approach and output, not all were university-affiliated.  Some were within universities modelled on the European research universities —with libraries established as repositories and markers of knowledge, and research laboratories celebrated as places of scientific enquiry. Johns Hopkins University was the American realization of the European model and was likely the gold standard to which Abraham Flexner compared all other medical schools when he was asked by The Carnegie Foundation to review the more than 150 medical schools in Canada and the United States.

In 1910 Mr. Flexner’s final report, proposed an educational structure for medical education, one rooted in the bio-medical model which identified teaching hospitals, libraries, and laboratories as necessary elements for a medical school. The Flexner Report also drastically reduced the number and diversity of medical schools. By outlining what he deemed to be the proper training to produce physicians skilled to ensure the safety of the population, Flexner’s report resulted in institutional homogeneity to a white, male, Eurocentric norm (Harley, 2006).

Flexner proposed at least two years of science focused education prior to a standardized four-year medical education:

“In general, the four-year curriculum falls into two fairly equal sections, the first two years are devoted daily to laboratory sciences, – anatomy, physiology, pharmacology, pathology; the last two to clinical work in medicine, surgery, and obstetrics. The former are concerned with the study of normal and abnormal phenomena as such; the latter are busy with their practical treatment as manifested in disease” (Flexner, 1910, p. 57)

This two-plus-two model, linking two years of learning in scientific disciplines with two years of clinical training in hospital and outpatient settings, quickly became the norm.  Learning in medical schools focused on the acquisition of information, on the transfer of knowledge from professor to student, from book to mind. Globally, more than a century later, we still see centralized, content-focused, science-based, university-affiliated medical education where the accepted tools of medical pedagogy are: didactic schooling; exposure to scientific disciplines, and clinical preceptorships; and criterion-based assessment with normative ranking within class groupings of peers.

The Starting Point

Since Flexner, the first two years of a medical education have focused heavily on the rapid acquisition of vast amounts of content—an immersion in Ideas. The scientific disciplines are primarily taught as discreet entities with little cross-pollination until the clinical application in the final two years of medical school when integration across disciplines and Connection between the student’s basic sciences education and the patient context became relevant. The final two years of medical school are a mixture of clinical learning in hospitals and outpatient facilities with graduated contributions to clinical service in those environments. The medical student takes content from lecture and laboratory work in the first two years and applies it to the assessment and care of patients.

From the perspective of the ICE model[3] we can see a heavy focus on the transmission and acquisition of Ideas, both in terms of pre-medical preparatory education and in the first two years of medical school itself. The final two clinical years can be viewed as a time of making Connections between prior learning and the clinical environment, of connecting theory to the reality of patient context.

Step 1. Problem-Based Learning: From Ideas to Connections—Let the Problem be the Teacher

As new research findings alter the practice of medicine so too does evidence inform pedagogy. Over time we have seen changes but few direct challenges to Flexner’s two-plus-two model. Only two (McMaster and Calgary (Lampard et al., 2021) of the seventeen medical schools in Canada offer their programmes over three years. In the late 1960s, McMaster University’s medical school was founded around the idea that students should be immersed in the richly connected, extended scenario of the patient presentation, and that those should be the anchor for learning. Both McMaster and Calgary employed problem-based learning (PBL) curricula and intentionally constructed system-based patient scenarios through which students learnt the basic sciences and clinical skills relevant to the cases. PBL starts with the highly complex and connected patient case and challenges students to understand it by asking questions to structure their learning. The goal is not to arrive at an answer or to solve the case, but to learn from it. The traditional and hierarchical direction of learning from microscopic to macroscopic was reversed in PBL where learning begins with the person/patient and the student learns specific content (Ideas) in order to more deeply understand the patient case. Information is learned in the clinical context and applied and Connections are made to patient care immediately. The approach recreates an iterative process authentic to the clinical setting.

From the perspective of ICE, we can see the McMaster and Calgary models as desire to teach ideas in the web of connections in which they exist, to take Ideas, Connections, and Extensions out of a linear hierarchical relationship, and instead to train students to understand the Connections as they acquire the fundamental Ideas of medicine and hone analytical skills to evaluate and extrapolate Extensions to their learning.

Step 2. Under Construction

In the 1980s in Ontario, a process of patient and consumer consultation (EFPO – Educating Future Physicians of Ontario)(Neufeld et al., 1998) was undertaken to elucidate societal expectations of physicians and to guide medical education. The ensuing distillation of public expectations of physicians into defined roles would come to be known as the CanMEDS roles (Royal College of Physicians and Surgeons of Canada, n.d.). Each of the seven roles (professional, communicator, collaborator, scholar, health advocate, leader, medical expert) parsed out the interconnected actions and expectations of physicians and was defined by a set of competencies.  This framework shaped and organized aspects of medical education and has been adopted internationally and contributed to competency-based education in postgraduate College of Family Physicians Canada Triple C)[4] and undergraduate medical education. (Butt & Duffin, 2018)

In medical education competencies are defined as “an observable ability of a health professional, to integrating multiple components such as knowledge, skills, values, and attitudes” (Frank J et al, 2010, pp. 638–645); competencies became the observable, measurable assessable substrate of competency-based medical education (CBME). In Flexner’s two-plus-two model, medical education was time-based, with a set beginning and end without regard for a student’s individual interests, aptitudes, or career goals. When educators began to work with the CanMEDS framework and competencies it became necessary to consider learning as something more than timed exposure to a discipline. CBME brought the linear and architectural construction of medical education into question, casting doubt on perceptions that “(c)ompetencies can be assembled like building blocks to facilitate progressive development.”(Frank J et al, 2010, pp. 638–645) CBME is a behaviourist approach with clear expectations and standard performance goals based on competencies. No longer was mastery of content or passage through the two-plus-two programme enough to make one a physician.

CBME is structured with graduated responsibility and individualized rates of learning. In this model, expertise is the normative standard and it requires mastery of defined content and the demonstration of specific skills and competencies. The detailed picture of progress, skills, interests, and challenges is held in a portfolio of assessments, containing micro-formative instead of large summative assessments. Increased responsibility is not granted by one mentor-preceptor, instead, the role of the arbiter is played by the proxy master of large data sets—an accumulation of specific data points that indicate progress and readiness for increased challenge and responsibility. This model documents concrete actions but can risk overlooking ways to assess integration through Connections and Extensions. One can argue that CBME allows learners more latitude in terms of timing and sequencing of learning with the opportunity to focus on areas of interest and that by tracking and documenting the attainment of competencies learners can document their own trajectory of mastery from novice to expert.

Approaches like CBME are helpful to clearly define competencies and the constituent skills, but the risk is that in so doing we might actually limit learning to just those elements. Early proponents listed the “threat of reductionism.”(Frank J et al, 2010, pp. 638–645) as a predictable risk of CBME.  At the same time, CBME can be considered a more ecological approach to constructivism, one that is iterative and allows for emergent and integrated learning outcomes. The application of the ICE philosophy in this context might eschew the reductionist possibility of CBME and ensure that learning and assessment embrace unlimited possibility. This inclusion of ICE in CBME would position the ability to see Connections and find Extensions as core competencies for medical education.

Step 3. Integration for Connections and Extensions

Students are no longer expected to graduate from medical school ready to practice, as they would have in the time of Flexner, but ready to pursue postgraduate training in a residency programme that is either generalist or specialist. The generalist is dedicated to connected coherence and is expected to see the patient in their full psychosocial context, advocate for, and modify approaches to ensure equity of care and social accountability. The generalist has a wide knowledge base and is called upon and expected to make multiple and varied Connections and Extensions.  The specialist has deep mastery of a defined area and is valued for expertise that includes the ability to make Connections and Extensions over a deeper but more narrow field. Whether generalist or specialist, the pace of new information is such that no physician can practise with a static body of knowledge, new information must constantly be integrated into each physicians’ existing knowledge base. In the ICE model, students compare their own learning to their own previous states (Fostaty Young, 1995 p. 2) and it is this skill that is required for life-long learning in the ever-changing and expanding fields of clinical practice. Medical education must include opportunities for students to assess their own learning and build self-regulatory competence which is a professional expectation of physicians.

The clinical years of medical education have a generalist range and are divided into blocks or rotations measured in weeks—mini-apprenticeships where students learn the content and culture of various specialties. These core block experiences in which students master the skills and behaviours required to perform in that context are typically delivered in a university teaching hospital, as Flexner wished. The work for the student is performative and normative.

Over time, there has been more learning in ambulatory and community settings, places of rich learning opportunities. One such approach is the Longitudinal Integrated Clerkship (LIC), a community-based experience in the clinical years of medical school. LICs have been increasing in number steadily over the last 20 years. In the LIC model students are attached to a preceptor rather than a specific hierarchical team providing hospital service, and blend learning from multiple disciplines to care for people, rather than performing the acts of a discipline. The model is varied in its implementation but is based on the continuity of relationships, relationships between student and preceptor, student and patients, and student and place. The student is welcomed into an established medical community and given a meaningful role. Legitimacy is conferred and the student becomes a functioning member of a community of practice. The student is known as part of the team and comes to know patients over time—content, context, and clinical application are integrated. In this model, students are challenged to recall previously learned content and apply it in a different context, and competency is demonstrated by the ability to apply learning in a variety of ways, to connect knowledge in new ways, to detect patterns, and make creative Connections. Students follow patients over time and follow their journey through the health care system. Students are encouraged to make Connections across disciplines and care environments and the Extensions of learning beyond the mandatory encounters and core content of a traditional discipline-based core block clerkship.

When students learn in discipline-focused blocks they may develop a false sense that things are clear—in the cardiology clinic almost all chest pain will be cardiac in origin. The LIC may be seen as an ecological constructivist endeavor, one in which the student moves across the landscape of a health care system and comes to know its topography. In the LIC model, students learn across disciplines simultaneously and will be expected to assess complex and undifferentiated problems. There is an inherent growth orientation to this model of clinical education where the students, immersed in the world of Connections, learn how systems and individuals interact, and by seeing undifferentiated problems they need to be creative and think critically. Students deepen their learning by applying knowledge from one context to another. By placing students in these environments, we show our respect for them; we teach that we value them as participating members of the health care team. We also demonstrate that we trust them to cope with the complex reality of practice and to be part of the real work of the environment. We teach them that they are not just tourists; they are team members and contributors to the care they witness and, increasingly over time, provide.

In the ICE model:

“at (Fostaty Young, 2005) the Extensions stage, new learning is created from old so that students are able to use it in novel and creative ways that may well be quite far removed from the original learning context. The learning becomes internalized to such a degree that it helps students answer extrapolative questions, articulate implications, and anticipate outcomes.”

This can also be said of the LIC model where there is unscheduled time for students to pursue learning opportunities and follow patients over time. This affords students the space and freedom that comes from decreased structure. When teachers relinquish control in the learning environment there is room for possibility, for Connections and the application of previous learning in new environments and novel situations. Connections are what happen for the student, they are not observations that we can provide to students in a lecture, we need to engage students in real experiences to allow them to make their own connections, to give life to the material and their own learning. In both the LIC and ICE models, educators create experiences to allow learning to happen rather than dictate it. Those who educate in these ways know that prescriptive objectives focus students’ attention only on that which is asked, thus limiting their learning.  By opening up learning, loosening the controls, by setting fewer parameters and objectives, students are freed from the limits of our expectations; they experience the freedom to learn what is linked to practice, to follow their interests, and to learn in service of their patients. Is this not the ultimate goal of a medical education? Permissive experiences invite expansive learning.

Step 4. Decentralizing Education—The Library is With You

Community-based educational experiences are greatly aided by the decentralization and democratization of information with the internet. Students are no longer tied to labs and libraries for information and we have to wonder if some of the reasons for Flexner’s desire to centralize medical education might no longer hold.

Freedom from the library as a physical space further dismantles the need for the structure enshrined by Flexner and has opened possibilities for other kinds of learning—learning in the lived spaces of context and Connections. By situating foundational learning in communities, students learn ideas and make connections simultaneously, as the constructed cases of PBL were designed to do.