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Social Science & Medicine 70 (2010) 1672e1676

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

Recipes for medical education reform: Will different ingredients create betterdoctors? A commentary on Sales and Schlaffq

Cynthia Whitehead*

University of Toronto, Faculty of Medicine, Women’s College Hospital, 76 Grenville St., Toronto, ON M5S 1B6, Canada

a r t i c l e i n f o

Article history:Available online 10 March 2010

KeywordsMedical educationHealth care reformQuality of health carePhysiciansUSAReviewTraining

q Zubin Austin offered his time most generously foin this paper. His comments on drafts were invaluabcalibre of this piece. Brian Hodges and Nick Pimlinsightful comments. My sincere thanks to each of th* Tel.: þ1 416 323 6247.

E-mail addresses:cynthia.whitehead@wchospital.ca, c

0277-9536/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.socscimed.2010.02.017

Sales and Schlaff’s article “Reforming Medical Education: Areview and synthesis of five critiques of medical practice” (2010) inthis issue of Social Science & Medicine examines five areas todemonstrate the inadequacy of current medical training pro-grammes in the US. The authors argue that the critiques of medicalpractice offered up by quality, evidence based medicine (EBM),population medicine, health policy and heuristics can be synthe-sized to show that “medicine is practiced in a context of social andorganizational structures distinct from its bio-medical substrate”(Sales & Schlaff, 2010). They propose that increasing physiciantraining in the social sciences during medical school and residencywill be an effective way to produce better physicians. In addition,they advocate for changes to medical admissions processes andpre-medical training to include assessment of broader attributesthan facility in natural sciences, and a greater focus on criticalthinking rather than memorization.

Sales and Schlaff (2010) raise important issues which arecongruent with many initiatives currently underway in medicaleducation. Between calls for greater social responsibility to debatesabout professionalism to the outcomes-based curricular modelsthat are the current trend in medical education, there is a rallyingcry for change. Much attention is currently being paid to turning

r discussions about the ideasle and greatly improved theott also provided wise andese colleagues.

ynthia.whitehead@utoronto.ca

All rights reserved.

out the right “product” by the completion of training. Solutionsfocus on labelling and defining the product followed by suggestionsfor curricular change that, it is hoped, will more effectively andefficiently produce this end result. Sales and Schlaff argue thatmore social science embedded at various points in the curriculumand linked to clinical practice settings will transform the kind ofdoctors that emerge. Their critical synthesis is: “in short, physiciansmust be social as well as natural scientists” (Sales & Schlaff,2010). The incorporation of specific social science skills and tech-niques into medical training, they posit, will provide physicianswith the tools and values needed to understand and work withinthe social, organizational and political frameworks of the medicalsystem.

Fewwould argue against the notion that the social sciences playa pivotal role in medical education. However, it is not clear thatmore science (albeit different science), if applied within currentparadigms, is the solution to physicians’ limited “ability to confrontcontemporary health care problems” (Sales & Schlaff, 2010). Thenotion that the adjustment of curricular content will change theway physicians work within the health care system is common;educators hope that tweaking the curriculum with an extra drib ofcommunication skills training, or a drab more on the social deter-minants of health will shift the balance. Pauli, White, andMcWhinney (2000a, 2000b, 2000c), however, have eloquentlyidentified the need for a fundamental paradigm shift in terms ofmedical belief systems and medical scientific thinking. Thecomplex and uncertain world of clinical medicine and the thera-peutic relationships that must be formed between practitionersand patients cannot be approached only from a positivist scientific

C. Whitehead / Social Science & Medicine 70 (2010) 1672e1676 1673

frame of reference. Medical education should incorporate anunderstanding of complex power relations, hierarchy, healingrelationships and the social roles of health and health care provi-sion. Medical education must recognise the processes by whichprofessional identity and values develop as trainees are socialisedinto this powerful and privileged profession. It is improbable thattinkering with recipes for doctor production will create significantchange if educators do not also seriously address the processes oftraining, and critically analyse how social, educational and orga-nizational settings impact upon the values, identity and cognitiveskills of medical trainees.

Transforming medical education

The authors’ call for transformation of medical school admissioncriteria, pre-medical training andmedical education resonates withmany recent trends in medical education. The belief that bio-medical training alone is insufficient for the creation of physicianswho will function effectively in health systems is widespread.Current educational frameworks in many countries are adjustingtraining to address concerns raised by Sales and Schlaff. TheAmerican Medical Association’s Initiative to Transform MedicalEducation (2007), the British report, Tomorrow’s Doctors (2009),and the CanMEDS competency framework (Frank 2005) developedin Canada and adopted by many countries worldwide, all incor-porate ideas suggested by the authors. That a physician needs broadsocial training is not, however, a concept new to our times. Rather,it has been a recurrent theme, going back at least as far as the 1910Flexner report. While the educational impact of this report was theestablishment of academic medical centres with a strong bio-medical focus in the US, Flexner himself explicitly proposeda broader approach, arguing that

the physician’s function is fast becoming social and preventive,rather than individual and curative. Upon him society relies toascertain, and through measures essentially educational toenforce, the conditions that prevent disease andmake positivelyfor physical and moral well-being. It goes without saying thatthis type of doctor is first of all an educated man. (Flexner 1910,p. 26)

Flexner decried the overemphasis on scientific medicine thatemerged after his 1910 report, proclaiming in 1925 that “scien-tific medicine in Americadyoung vigorous and positivisticdistoday sadly deficient in cultural and philosophic background.”(Flexner, 1925, p. 18) Over the decades, Flexner’s ideas have beenrevisited. His “bible” of medical education has been the sourceof insights for those seeking to adapt medical education to fitwith the values of the era (Cooke, Irby, Sullivan, & Ludmerer,2006; Vevier, 1987). In this, the 100th anniversary of Flexner’sreport, medical educators once more seek wisdom in Flexner’swritings (Caraccio, Wolfsthal, Englander, Ferentz, & Martin,2002; Zelenka, 2008). Yet again educators are looking for waysto incorporate a broader social framework into medicaleducation.

Current efforts to transform medical education frequently focuson outcomes-based models. These are viewed as a way to increaseaccountability, responsiveness to social needs and transparency ofmedical training. Outcomes-based education hypothesizes that ifthe desired product can be defined, and appropriate assessmenttools developed to ensure that the trainees have achieved thesecompetencies, then the job will be done. Explicitly stating what isaimed for is thought to simplify the process of getting there. Thisapproach has spread like wildfire through the medical educationcommunity, leading to a plethora of competency statements and

frameworks. Defining the correct ingredients to fit the recipe’sframework is deemed necessary to produce a model physician.

Are checklists of competencies and a progressive accretion ofmore “stuff” (be it knowledge, skills, or behaviours) actually thebest way to create the “right stuff”? What, fundamentally, are theproblems that medical educators since Flexner have been trying torectify? And why are there recurrent efforts and calls for change,with many of the same issues emerging with each new trans-formation initiative? Is it simply the fact that educational pro-grammes regularly need to be modified to reflect the values ofparticular times? Or do many attempts at change focus solely onknowledge, skill, roles or behaviours which will not fundamentallyalter the way physicians engage cognitively, morally and socially insociety and the health care system? Perhaps most changes aim toproduce only slightly different doctors, not choosing to questionmedicine’s favoured paradigms and beliefs.

To decide just how far-reaching we desire medical educationreform to be, it is important to consider the nature and implicationsof current medical ways of knowing and being. Medical ways ofknowing refers to the dominant forms of knowledge and reasoningin clinical medicine, including tensions between different knowl-edge paradigms. Medical ways of being refers to the complexinterplay between professional identity, personal identity,authority, privilege, and values.

Medical ways of knowing

Medical educators need to consider the types of knowledge thatare most dominant and valued in clinical medicine, and how theserelate to other knowledge forms. In spite ofmedicine’s firm and fondbelief that the practice of medicine is fundamentally scientific, thethought processes of physicians frequently do not follow a scientificpattern. To the chagrin of university science professors, the basicsciences are approached by many pre-medical students as a set offacts to be memorized in the pursuit of a good grade rather than asconcepts to be explored intellectually. While medical schools teachphysiology, pathology, anatomy and pharmacology, trainees do notnecessarily approach these subjects scientifically. Instead, studentscan function in clinical settings using these as learned facts andconcepts to help recognize clinical patterns. Richard Smith, formereditor of the British Medical Journal, argues persuasively that mostdoctors are not scientists, and that, when asked, few considerthemselves to be so. Smith defines a scientist as “someone whoconstantly questions, generates falsifiable hypotheses, and collectsdata fromwelldesignedexperiments.”Physicians, in contrast “followfamiliar patterns and rules, often improvising around these rules. Intheir methods of working they are more like jazz musicians thanscientists.” (Smith, 2004, p. 7454) If physicians’ thought processes arenot “scientific” then adding more science (whether social or naturalscience), as suggested by Sales and Schlaff (2010), is perhaps not thebest way to create better thinking physicians.

Pattern recognition is widely considered to be a dominant modeof medical diagnostic thinking. Bordage (1994) has analysed thestructures of medical knowledge and provided a framework todescribe the organization of knowledge that allows for expertdiagnostic reasoning abilities. The expertise literature supports thenotion that specific cognitive structures provide a highly efficientand effective way for experts to organize and use knowledge(Bereiter & Scardamalia, 1993; Schmidt, Norman, & Boshuizen,1990). As described by Moulton, Regehr, Mylopoulos, and MacRae(2007), Bereiter and Scardamalia highlight the differencebetween experts and experienced non-experts, suggesting thatexperienced non-experts operate using automatic, nonanalyticprocesses, whereas experts resort to analytic thinking when theyidentify that an automatic approach does not suffice. Moulton

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suggests that knowing when to “slow down” is a hallmark of expertthinking, with expert judgement being

an expert’s ability to respond effectively in the moment to thelimits of his or her automatic resources and to transitionappropriately to a greater reliance on effortful processes whenneeded. With adequate judgement, the expert will slow downwhen appropriate and take the time to ensure that the muddyproblems of practice will be correctly named and framed.(Moulton et al., 2007, S114)

Understanding the nature of clinical medical thinking in thisway, Moulton suggests that improvement in medical thinkinginvolves looking for ways to engage in reflection, pay attention,develop situation awareness and exert cognitive effort. Given theabundance of literature showing how poor self assessment is(Kruger & Dunning, 1999), there needs to be significant researchfocus on how to better inculcate these practices in trainees. Salesand Schlaff’s (2010) suggestion that “a searching mind,” devel-oped through additional philosophy, literature, or social sciencecourses prior to medical school, will lead trainees to “self-reflect,avoid cognitive errors and improve” might not be quite enough.Broader pre-medical training is intrinsically worthy and desirable.But it is not clear whether a liberal arts education can prevail overthe ultra-competitive pre-medical culture where high marks andstrong resumes trump intellectual development. Prescribedportions of Machiavelli and Mozart will not likely be sufficient toreduce cognitive errors in clinical reasoning.

Clinical reasoning, QI and EBM

Analysing clinical thinking epistemologically might help explainthe lack of physician buy-in to EBM and Quality Improvement (QI)approaches so correctly noted by Sales and Schlaff. Perhaps physicianlack of engagement in thesemodels relate inpart to the fact that theseapproaches utilise and value different forms of knowledge from thepattern recognition dominant in clinical diagnostic reasoning. If so,simply addingmore training in these approachesmay not achieve thedesired goal of enhancing physician usage of these forms of knowl-edge. QI, for example, “is based on engineering principles, specificallysystems theory” and has evolved “from a foundation based on logicalpositivismdthe belief that there is a singular entity wherephenomena can be explained, predicted and controlled” (Colton,2000, p. 13). Clinical practice abounds with phenomena that areunexplained, unpredictable and uncontrolled. Analysis of the benefitsand limitations to the questions asked and solutions proposed by theQIparadigmmight provideabroader approach to anunderstandingofquality within complex health systems. In addition, QI solutions ofteninvolve the introduction of standardized processes of care. In thisway,QI shifts authority from the individual practitioner to health careorganizations. Given that medical culture highly values autonomy ofpractice (Marjoribanks & Lewis, 2003), and considers professionalautonomyessential for the exerciseof professional judgement, it isnotsurprising that physicians are reluctant to embrace practices that limitchoice of the individual practitioner. Hence, physician lack ofinvolvement with the QI paradigm may relate both to issues of epis-temology and autonomy. If so, these will need to be addressed inlooking for ways to engage physicians in the Quality movement.

In their EBM critique, Sales and Schlaff comment on physicians’unwillingness to accept evidence based on epidemiologic orempiric data. Perhaps physician lack of comfort and skill with thetechniques of EBM is only part of the problem, and as with QI, issuesof epistemology and authority may also be important. In EBM, thereasoning processes, knowledge claims and definitions of evidenceare quite different from clinical reasoning (Norman,1999). For EBM,the “overarching concern is for validity and the veracity of claims

derived from the empirical clinical literature” whereas the processof medical practice “is dialectical, dynamic, pragmatic and context-bound” (Upshur & Colak, 2003, p. 295). As well as epistemologicaldifferences, reliance on EBM hierarchies of evidence raises ethicaland practical concerns (Borgerson, 2009). The EBM approach canlimit the type of evidence that is valued, devalues theory, and doesnot acknowledge the essential role that judgement plays in inter-preting evidence (Giacomi, 2009; Goldenberg, 2009). Can socialand ethical values less amenable to descriptionwithin the evidencehierarchy be adequately incorporated into an EBM approach? Inaddition, many clinicians question the appropriateness and appli-cability of the ever-proliferating set of EBM-derived guidelines andbest practices to “real” clinical practice, particularly with complexpatients with mental health issues or medical co-morbidities(Gupta, 2009; Upshur & Tracy, 2008).

EBM and its hierarchies of evidence have, nevertheless, becomeaccepted “truths” in the development of best practice guidelines,and payment systems reward physicians who perform according tocertain guideline standards. This leads to increased authority of EBMexperts compared to individual physicians; as with QI, physicianswho value and expect to be able to practice with clinical autonomymay not embrace this challenge to their individual authority andexpertise (Rappolt, 1997). There is absolutely no doubt that enor-mous benefit can be derived from incorporating EBM approachesinto clinical practice. However, solutions to the “EBMgap”mayneedto be sought in exploration of these complex ethical, socio-politicaland epistemological issues rather than, as Sales and Schlaff suggest,by using social science training to increase the willingness ofphysicians to “apply science based on empiric evidence and epide-miologic data” (Sales & Schlaff, 2010).

Medical ways of being

Medical ways of knowing, including implications of knowledgetypes for physician autonomy and authority, clearly need to beanalysed to understand how physicians react to and utilise differentforms of knowledge. Similarly, medical ways of being require carefulexamination when proposing changes to physician involvement insocial, political and organizational structures. Medicine has helda dominant and authoritative role amongst health professions,influencing social views of health and healing. Medical identity andmedical values are rooted in power relations and social structures, aswell as in myths and metaphors of healers and health. A largeliterature examines medical socialization (Coulehan & Williams,2001; Hafferty & Franks, 1994), and professionalism articlesabound (Cohen, Cruess, & Davidson, 2007; Hafferty & Levinson,2008; Wear & Kucezewski, 2004). That “the construct of profes-sionalism is central to the identity of a doctor” (Martimianakis,Maniate, & Hodges, 2009, p. 836) is not a proposition likely toinvite significant debate. However, the historical nature of thisidentity and the implications of changing training models toprofessional identity development have significant impact on issuesraised by Sales and Schlaff, particularly those of populationmedicineand health policy.

Medical identity development

It is commonly acknowledged that the process of becominga doctor is taxing and transforming. Medical training places moraland ethical demands on trainees, in addition to requiring hardworkand significant knowledge acquisition. As Flexner wrote:

Between the young graduate in medicine and his ultimateresponsibilitydhuman lifednothing interposes..the issues of

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life and death are all in the day’s work for him from the veryfirst. (Flexner 1910, p. 24)

Hafferty highlights the transformative nature of medical iden-tity development, using the concept of resocialization: a “purpose-ful social process where certain aspects of one’s prior self arereplaced by new ways of thinking, acting and valuing..It isa processdfor better and/or for worsedto change hearts andminds” (Hafferty, 2009, p. 63e64).

The importance of time in this transformation has beenemphasized:

long hours on duty have come at a cost but they have allowedtrainees to learn how the disease process modifies patients’ livesand how they cope with illness. Long hours have also taughta central professional lesson about personal responsibility toone’s patients. (Drazen & Epstein, 2002, p. 1272)

As medicine grew in stature during the twentieth century,ensconced in academic institutions and deriving authority from theadvances of clinical science, the journey to become a physicianwasdepicted using the mythology and metaphor of the hero. Central tothe development of a hero is the hero’s journey. As described byNorthrup Frye:

A journey is a directedmovement in time through space, and in theideaofajourney therearealways twoelements involved.One is thepersonmaking the journey; theother is the road, path, or directiontaken, the simplest word for this beingway. (Frye, 1990, p. 212)

Such a journey requires a person, a path, and time for thejourney to unfold.

Does the current approach to medical education adequatelyallow for the professional resocialization described by Hafferty(2009)? Certainly, the demise of militaristic, brutal, hierarchicaland demeaning features that once categorized residency trainingshould come as a welcome relief to medical educators. Thankfully,demonstrating that one is able to withstand long hours of work andsleep deprivation no longer confers automatic title as responsiblephysician. But if the former medical hero model of training isrelegated to a bygone (and by nomeans golden) erawhere does thisleave the journey to become a healer?

According to Frye, time is an essential element of such a trans-formative journey. However, a key shift in the language andapproach of outcomes-based models of education is the devaluingof time and process. Time-basedmodels are deemed inefficient andinappropriately focussed on service rather than education (Frank &Danoff, 2007; Harden, 2002). Instead, a curriculum that focuses onspecific competencies is considered to better allow learners tosucceed. But will competencies assembled block by block coalesceto form a coherent medical identity?

Along with the dismissal of time and process, many of theoutcomes-based competency frameworks have adopted whatHodges (2009) describes as a production model of discourse. Afactory model lends itself well to the notion of quick fixes with theinsertion of different bits into the assembly line of medicaleducation leading tomore efficient and effective doctor production.Hodges notes that in the current production discourse, the studentis framed as a raw material. Hence this production discourseremoves the person from the process. By combining the productiondiscourse with outcomes-based language, both person and time,and hence any sense of journey, vanish.

Professionalism

What kind of professionalization will occur as a result ofa factory production model? The explosion of professionalism

literature speaks to the concern and lack of consensus on thefundamental nature of professionalism. Hafferty provides a cogentsummary of the inconsistencies in current approaches to profes-sionalism, arguing that if professionalism is seen merely as atti-tudes and behaviours a completely different pedagogical approachis needed than if it is conceived as relating to values and self-identity (Hafferty, 2009, p. 54).

Outcomes-based frameworks tend to use roles and behavioursto define competencies. However, professionalism must also beconsidered in historical and social context; something that thesecompetency-based frameworks do not easily incorporate.Martimianakis et al. (2009) review a range of approaches toprofessionalism, and argue that it is limiting to frame profession-alism as either a list of behaviours or a role played, as it

leads to an overemphasis on codes of behaviour and misses theinfluencesofcontext, institutionsandsocio-economicandpoliticalconcerns in the creation of the definitions.[which] may actuallyserve as away for a profession to safeguard its power in relation tothe state.and to defend its authority in relation to other profes-sions and occupations. (Martimianakis et al., 2009, p. 832)

Constructs such as professionalism are “too complex and nuan-ced.to be reduced to a simple checklist of individual characteristicsand behaviours” (Martimianakis et al., 2009, p. 834). Instead,professionalism must be seen as changing and contextual, and inti-mately connected to issues of power and control of health agendasby professions. The uses and meanings of any construction ofprofessionalism constrain and limit discussions of health anddisease, and impact notions of equity and social justice. Theprofessional behaviour of an individual physician cannot be under-stood separately from the political and economic forces that driveprofessional organizations. This is not to say that individual char-acteristics are irrelevant; many physicians enter the medicalprofession with a desire to heal, cure and in general perform anhonourable role in society. Medicine is a profession where it isrelatively easy to feel morally virtuous at the same time as enjoyinghigh social status and economic benefits. But such easy virtue maylimit the extent to which the profession is willing or able to examineunderlying health inequities. The profession’s language and practicesof power constrain what approaches are seen as possible by medicalpractitioners.

To return to Sales and Schlaff’s article (2010), population healthand health policy perspectives need to be considered in terms of thetension between professional authority and professional values thatrequire social change. If physicians address the social determinantsof health, for example, they tackle issues with thorny political, socialand economic consequences. Confronting social inequities alsoinvolves confronting social privilege (such as that which physiciansas a group enjoy). Advocating for better physician understandingof health policy puts physicians in the uncomfortable position ofexamining tensions betweenwhat might be good for health systemsversus what benefits physician pocketbooks. There are many physi-cians engaged in noble work with organizations such as Médecinssans Frontières. The medical profession as a whole, however, isgenerally only prepared to take a qualified stance on social inequitiesandhealth systemstructures; one that usually doesnot challenge theboundsof professional privilege.Medical trainees surely donot fail tosee that the profession only partially promotes change, and thatsocial and organizational engagement often remains at a level ofsymptomatic solutions.

Summary

Sales and Schlaff highlight the complex context of medicalpractice and emphasises the need to train physicians to work

C. Whitehead / Social Science & Medicine 70 (2010) 1672e16761676

effectively within organizational structures. Sales and Schlaff justlypoint out that many current educational reform efforts do notadequately address the degree of change required, and propose thatthe addition of more social science training will address this deficit.However, simply adding social science training to current produc-tion-focussed educational structures may not suffice. Instead, theimplications of current medical ways of knowing and medical waysof beingmust be taken into account. Considerationmust be given towhich desired new approaches are compatible with current para-digms, which would require fundamental change, and what theimplications of such change might be. When are different ingre-dients sufficient, and when do the recipes for doctor productionneed to be examined? If we are not realistic about the nature andscope of educational reform, it will not be surprising if currentchanges once more disappoint, with renewed calls for medicaleducation transformation likely appearing in yet a new form sometime soon.

References

American Medical Association. (2007). Initiative to transform medical education:Recommendations for change in the system of medical education. AmericanMedical Association.

Bereiter, C., & Scardamalia, M. (1993). The need to understand expertise. In.Surpassing ourselves: An enquiry into the nature and implications of expertise(pp. 1e24). Chicago, Ill: Open Court.

Bordage, G. (1994). Elaborated knowledge: a key to successful diagnostic thinking.Academic Medicine, 69(11), 883e885.

Borgerson, K. (2009). Valuing evidence: bias and the evidence hierarchy ofevidence-based medicine. Perspectives in Biology & Medicine, 52(2), 218e233.

Caraccio, C., Wolfsthal, S. D., Englander, R., Ferentz, K., & Martin, C. (2002). Shiftingparadigms: from Flexner to competencies. Academic Medicine, 77(5), 361e367.

Cohen, J. J., Cruess, S., & Davidson, C. (2007). Alliance between society and medi-cine: the public’s stake in medical professionalism. JAMA, 298(6), 670e673.

Colton, D. (2000). Quality improvement in health care: conceptual and historicalfoundations. Evaluation & the Health Professions, 23, 7e42.

Cooke, M., Irby, D. M., Sullivan, W., & Ludmerer, K. M. (2006). American medicaleducation 100 years after the Flexner report. NEJM, 355, 1339e1344.

Coulehan, J., & Williams, P. (2001). Vanquishing virtue: the impact of medicaleducation. Academic Medicine, 76(6), p.s. 598e604.

Drazen, J. M., & Epstein, A. M. (2002). Rethinking medical trainingdthe criticalwork ahead. NEJM, 347, 1271e1272.

Flexner, A. (1910). Medical Education in the United States and Canada. A Report tothe Carnegie Foundation for the Advancement of Teaching. Bulletin NumberFour, New York. p. 24.

Flexner, A. (1925).Medical education: A comparative study. New York: The MacmillanCompany.

Frank, J. R., & Danoff, D. (2007). The CanMEDS initiative: implementing an outcomes-based framework of physician competencies.Medical Teacher, 29(7), 642e647.

Frank, J. (Ed.). (2005). The CanMEDS 2005 physician competency framework. Betterstandards. Better physicians. Better care. Ottawa: The Royal College of Physiciansand Surgeons of Canada.

Frye, N. (1990). Myth and metaphor. Charlottesville/London: University Press ofVirginia.

GeneralMedical Council. (2009).Tomorrow’s doctors. London:GeneralMedical Council.

Giacomi, M. (2009). Theory-based Medicine and the Role of Evidence: why theemperor needs new clothes again. Perspectives in Biology & Medicine, 52(2),234e251.

Goldenberg, M. (2009). Iconoclast of creed? objectivism, pragmatism, and thehierarchy of evidence. Perspectives in Biology & Medicine, 52(2), 168e187.

Gupta, M. (2009). Ethics and evidence in psychiatric practice. Perspectives in Biology& Medicine, 52(2), 276e288.

Hafferty, F., & Franks, R. (1994). The hidden curriculum, ethics teaching and thestructure of medical education. Academic Medicine, 69(11), 861e871.

Hafferty, F., & Levinson, D. (2008). Moving beyond Nostalgia and motives: towardsa complexity science view of medical professionalism. Perspectives in Biology &Medicine, 51(4), 599e615.

Hafferty, F. W. (2009). Professionalism and the socialization of medical students. InR. L. Cruess, S. R. Cruess, & Y. Steinart (Eds.), Teaching medical professionalism.Cambridge: Cambridge University Press.

Harden, R. M. (2002). Developments in outcome-based education. Medical Teacher,24(2), 117e120.

Hodges, B. D. (2009). The objective structured clinical examination: A socio-history.Berlin: LAP Press, ISBN 978-3-8383-0181-5.

Kruger, J., & Dunning, D. (1999). Unskilled and unaware of it: how difficulties inrecognizing one’s own incompetence lead to inflated self-assessments. Journalof Personality & Social Psychology, 77, 1121e1134.

Marjoribanks, T., & Lewis, J. (2003). Reform and autonomy: perceptions of theAustralian general practice community. Social Science & Medicine, 56,2229e2239.

Martimianakis, M. A., Maniate, J., & Hodges, B. H. (2009). Sociological interpreta-tions of professionalism. Medical Education, 43(9), 829e837.

Moulton, C. E., Regehr, G., Mylopoulos, M., & MacRae, H. M. (2007). Slowing downwhen you should: a new model of expert judgement. Academic Medicine, 82(10Suppl.), S109eS116.

Norman, G. R. (1999). Examining the assumptions of evidence-based medicine.Journal of Evaluation in Clinical Practice, 5(2), 139e147.

Pauli, H. G., White, K. L., & McWhinney, I. R. (2000a). Medical education, research,and scientific thinking in the 21st century (part one of three). Education forHealth, 13(1), 15e25.

Pauli, H. G., White, K. L., & McWhinney, I. R. (2000b). Medical education, research,and scientific thinking in the 21st century (part two of three). Education forHealth, 13(2), 165e172.

Pauli, H. G., White, K. L., & McWhinney, I. R. (2000c). Medical education, research,and scientific thinking in the 21st century (part three of three). Education forHealth, 13(2), 173e186.

Rappolt, S. G. (1997). Clinical guidelines and the fate of medical autonomy inOntario. Social Science & Medicine, 44(7), 977e987.

Sales, C. S., & Schlaff, A. (2010). Reforming medical education: a review andsynthesis of five critiques of medical practice. Social Science & Medicine, 70,1665e1668.

Schmidt, H. G., Norman, G. R., & Boshuizen, H. P. A. (1990). A cognitive perspectiveon medical expertise: theory and implications. Academic Medicine, 65(10),611e621.

Smith, R. (2004). Doctors are not scientists. BMJ, 328, 7454.Upshur, R. E. G., & Colak, E. (2003). Argumentation and evidence. Theoretical

Medicine, 24, 283e299.Upshur, R. E. G., & Tracy, S. (2008). Chronicity and complexity: is what’s good for the

diseases always good for the patients? Canadian Family Physician, 54,1655e1658.

Vevier, C. (1987). Flexner: 75 years later. A current commentary on medical education.Lanham/New York/London: University Press of America.

Wear, D., & Kucezewski, M. G. (2004). The professionalism movement: can wepause? The American Journal of Bioethics, 4(2), 1e10.

Zelenka, M. H. (2008). The educational philosophy of Abraham Flexner: Creatingcogency in medical education. Lampeter: The Edwin Mellen Press, Lewiston.Queenston.