Seeking Parity for Women in Academic Medicine: A Historical Perspective.

In this Invited Commentary, the author applies a historical lens to explore a fundamental paradox in U.S. medical education: the fact that long after women gained parity with men in matriculation to medical school, women remain highly underrepresented in leadership positions in academic medicine. The reasons for this are many and complex, but at the core are the subtle but hurtful indignities ("microinequities") experienced by women physicians and an academic culture that expects single-minded dedication to work, regardless of the costs to faculty members' personal lives. Achieving parity for women in academic leadership will require changing the culture of medical schools and teaching hospitals to correct these 2 fundamental obstacles. In recent years, many medical schools and teaching hospitals have made efforts to improve opportunities and satisfaction for women trainees and physicians, enacting reforms to improve work-life balance for all faculty. It is plausible to imagine a future in which flexible time frames to achieve tenure and promotion are universally available to both women and men, with high scholarly standards firmly maintained. If this occurs, it will represent a profound legacy for women in academic medicine, for their generations of professional sacrifice and advocacy for a more equitable culture will have changed its culture.

Reflections on Learning to Heal, Time to Heal, and Let Me Heal.

In this Invited Commentary, the author reflects on the contributions, influence, and continued relevance of his 3 books on American medical education: Learning to Heal, Time to Heal, and Let Me Heal. Collectively, the books provide a panoramic view of U.S. medical education spanning 2 centuries, and they cover virtually every topic and consideration pertinent to the enterprise. They are works of education as well as works of history, and as such, they identify the timeless principles and values-maintaining rigorous academic standards and serving as a public trust-that need to be protected at all costs if medical education in the United States is to retain its tradition of excellence and leadership. Learning to Heal describes the creation and maturation of the U.S. system of medical education, focusing on its cultural as well as its scientific roots; the book also defined the educational meaning and significance of these changes. Time to Heal introduced the term "learning environment" into the lexicon of medical education; it also inspired a number of notable experiments in undergraduate and graduate medical education. Let Me Heal provided the intellectual foundation for the 2017 version of Section VI of the Common Program Requirements of the Accreditation Council for Graduate Medical Education. However, the most notable contribution of these books is their analysis of medical education's ongoing challenges and opportunities; thus, they provide a framework for improving medical education and health care delivery in the United States today.

The history of calls for reform in graduate medical education and why we are still waiting for the right kind of change.

The author reviews the history of calls for reform of graduate medical education (GME), beginning with the Rappleye report of 1940, the first report on GME. Several continuities emerge. First, the reports have regularly called for GME to serve the "health needs of society." However, these perceived "needs" have continually been shifting as medicine and society evolve, thereby presenting GME a moving target. Second, the reports have regularly called for GME to focus more on education and less on service in order to avoid exploiting residents and compromising their training. Third, GME is a multifaceted subject. Reports on GME have typically addressed one part or another but not the subject as a whole. In their selectivity, the reports have reflected the particular perspective of the sponsoring groups. What the reports have generally not discussed, but what is underscored by calls for reform, is that GME is expensive, and any effort to improve its quality will be costly in terms of money, faculty time, or both. Thus, the profession has become complicit in maintaining the status quo. Any successful effort toward reform must acknowledge that GME functions as part of the larger health care delivery system, whose fate will ultimately determine the quality and robustness of GME in America.

Abraham Flexner and medical education.

The Flexner Report had its roots in the recognition in the mid-19th century that medical knowledge is not something fixed but something that grows and evolves. This new view of medical knowledge led to a recasting of the goal of medical education as that of instilling the proper techniques of acquiring and evaluating information rather than merely inculcating facts through rote memorization. Abraham Flexner, a brilliant educator, had the background to understand and popularize the meaning of this new view of education, and he took the unprecedented step of relating the developments in medical education to the ideas of John Dewey and the progressive education movement. Although the Flexner Report is typically viewed as a historical document--due to an understandable tendency to refer only to the second half of the report, where Flexner provides his famous critiques of the medical schools that existed at the time--this article argues that the Flexner Report is actually a living educational document of as much significance to medical educators today as in Flexner's time. The article analyzes Flexner's discussion of medical education and shows that his message--the importance of academic excellence, professional leadership, proper financial support, and service and altruism--is timeless, as applicable to the proper education of physicians today and tomorrow as in the past.

Reforming graduate medical education.

Because of the traditional subordination of education to service, graduate medical education (GME) in the United States has never realized its full educational potential. This article suggests 4 strategies for reasserting the primacy of education in GME: limit the number of patients house officers manage at one time, relieve the resident staff of noneducational chores, improve educational content, and ease emotional stresses. Achieving these goals will require regulatory reform, adequate funding, and institutional competency in the use of educational resources. Modern medicine grows ever more complex. The need to address the deficiencies of GME is urgent.

The clinical experience in medical education: past, present, future.

In the nineteenth century, clinical education in the United States was entirely didactic. Medical students attended lectures all day and were expected to commit the many details to rote memory. In the modern era, the clinical clerkship transformed students from passive observers to active participants in the learning process. In addition, the internship and residency provided learners the opportunity to assume responsibility in patient care. The strength of this clinical experience depends not only on the will of medical faculties but on the quality of the hospital learning environment.

Curricular reform in musculoskeletal medicine: needs, opportunities, and solutions.

Musculoskeletal medicine is not taught adequately in American medical schools and the predictable consequences are seen. Students cannot show cognitive mastery of the subject and lack confidence in this topic. To address this, the Academic Orthopaedic Society held a symposium on medical school education at its annual meeting in 2001. There, the panelists presented an analysis of the problem and proposed solutions. Specifically, it was noted that because of the autonomy of the various schools and their varied approaches to teaching, it would be unlikely that one monolithic and mandated plan could be effective on a national basis. Rather, successful reform would comprise a coalition-based effort to define learning objectives, to provide teaching materials, and to create forums for sharing resources. Recruitment of national organizations was thought to be essential. Finally, it was felt that although inadequate education is neither new nor necessarily unique among disciplines, the coming year or two, the beginning of the Bone and Joint decade, was seen to be a particularly auspicious time for attempting curricular reform.

The internal challenges to medical education.

This presentation shall discuss the major "internal" challenges to medical education--that is, challenges to achieving effective medical teaching that have arisen from the evolution of the science and practice of medicine. These issues are defined as "internal" in that they reflect the internal evolution of the profession and of academic medical centers, independent of the perturbations in medical education we are presently experiencing as a result of the hostile external environment of health care. Examples of these internal challenges include the growing "bench-bedside gap," the traditional tensions at medical schools between teaching and research, and the need to adjust medical education to meet the challenges imposed by chronic diseases. The need for "internal" leadership from within the profession to help solve some of the "external" problems of medical education shall also be discussed.