Presentation by Cynthia Whitehead in KMD1001, October 1, 2012

1. THE GOOD DOCTOR IN
MEDICAL EDUCATION
1910-2010
Cynthia Whitehead MD, PhD
1 October 2012

2. COMPETENCY
As a series of Roles depicted in the image
of a daisy

3. DATA SET
Educating Future Physicians for Ontario
(EFPO) archives
Thomas Fisher Rare Books Library,
University of Toronto

4. Results
“[EFPO had its] genesis following the 1986
Ontario physicians’ strike which revealed a
gap between the Ontario medical
profession and the public…. [EFPO will]
bridge the gap…”
Seidelman, EFPO archives 1992

5. “[EFPO began because of] concern that
the relationship between the medical
profession and the Ontario public was
showing signs of stress”
Neufeld et al CMAJ, 1993

6. DISCOURSES OF THREAT
“Legal issues, new patterns of reporting
responsibility and more vocal, better
informed patients often left physicians with a
sense of being threatened from unknown
sources.”
EFPO Working Paper 3, p 5

7. “[Physicians expressed] frustration over the
ways in which forces other than those
related to patient health and clinical
performance could alter the practice of
medicine.”
EFPO Working Paper 3, p 11

8. “Conflict and tension were described as a
characteristic of the way that many of these
physicians related to their environment.”
EFPO Working Paper 3, p 11

9. ROLES AS SOLUTION
“[Goal of EFPO is] to define the future roles
of physicians in Ontario in relation to
community health needs”
Neufeld & Sellers, EFPO archives, 1988

10. THE SOCIAL CONSTRUCTION
OF ROLES

11. “IMPLICIT IDEALS”
The health and illness expert
The health care resource consultant
The health care system advocate
The patient educator/enabler
The “humanist”

12. EFPO ROLES
Medical expert, clinical decision maker
Communicator, educator, humanist, healer
Collaborator
Gatekeeper, resource manager
Learner
Scientist, scholar
Health advocate
Person

13. NATURE OF ROLES?
“The roles provide a framework which is
helpful in identifying key issues related to
clinical problems . . .”
EFPO consensus summary 1992

14. PERCEPTION?
“ . . . however, the “roles” are a public
perception, not necessarily an ideal [and
the] “roles” are not necessarily of equal
importance.”
EFPO consensus summary 1992

15. ARCHETYPE?
“ [Roles] reflect the many needs and
expectations of Ontario society and outline
an archetype of the ideal physician.”
Maudsley et al Acad Med, 2000

16. ANALYSIS
Roles were proposed as solution (not
emergent from) EFPO process
Social construction of roles was contentious
and negotiated
Roles development occurred in specific
historical context, influenced by
discourses of the time

17. “If many medical procedures do not have
scientific justification, as is now claimed,
the state can sponsor ‘medical’ or non-
medical experts to determine the
‘scientific’ basis of medical practice itself.
A major underpinning of medical power, its
scientific basis, is being undercut.”
Coburn, 1997

18. There was a defensive component to roles
development
Professional competence is context-bound
and socially negotiated

19. Competency frameworks are not objective
ideals
Construction of any working model of health
professional will be affected by economic,
social and political factors that shape
health systems

20. FLOWER POWER?
How did we get here?

21. How have the discourses of the good doctor
in medical education changed in the past
century?
What are the implications and
consequences of these shifts?

22. METHODOLOGY
FOUCAULDIAN
critical discourse analysis
of roles development

23. METHODOLOGY
LANGUAGE
is socially constructed

24. LANGUAGE
Practices / Power

25. Regimes of
Truth

26. How far back to look?
Truth universally acknowledged that modern
medical education began with Abraham
Flexner’s 1910 Report on Medical
Education in the United States and
Canada

27. RESULTS
Series of discursive shifts in conception of
the good doctor from the Flexnerian
Scientist to the CanMEDS Roles

28. UNEXPECTED DISCURSIVE SHIFT
#1
Post-Flexner:
– Scientist vanished (science became
curricular content—the ‘stuff’ or
‘stuffing’)
– Character continued

29. UNEXPECTED DISCURSIVE SHIFT
#2
Late 1950’s:
– Characteristics emerged
– Character vanished

30. SCIENTIST to CHARACTER

31. SCIENTIST
The scientific inquirer
assembles facts from every
available source and by
every possible means.
Science resides in the
intellect, not in the
instrument.
(Flexner 1925)

32. CHARACTER
Modern medicine
cannot be imparted to
everyone; it can be
imparted to the best
advantage only to
persons of good
character, fixed
purpose, good native
intelligence, trained to
serious application
van Beuren, 1929

33. CHARACTERISTICS to COMPETENCE
(ROLES)

34. CHARACTERISTICS
[We must] identify the
relevant intellectual and
nonintellectual characteristics
that can be measured—then
we can proceed with some
confidence in applying the
findings to the problems of
medical education in filling
society’s need for medical
service
Gee 1957

35. COMPETENCE (ROLES)
Outcomes based education:
a performance-based approach
at the cutting edge of
curriculum development, [which]
offers a powerful and appealing
way of reforming and managing
medical education. The
emphasis is on the product—
what sort of doctor will be
produced—rather than on the
educational process.
Harden 1999

36. IMPLICATIONS
Who is a good doctor?
What is a good doctor?
What does a good doctor know?