The "new revolution" in medical education: fostering professionalism and patient-centered communication in the contemporary environment.

Everyone in medical education is aware of the legacy of Abraham Flexner, whose critical analysis of medical education after the turn of the 20th century led to a revolution in how physicians were taught. One could argue that a “new revolution” is occurring in medical education and concerns our increasing recognition that we need more effective methods to teach patient-centered communication, enhance cultural competence, and foster professionalism.1 Initial efforts along these lines involved programs to teach communications skills in traditional “history taking and physician exam” courses. Expanded efforts in recent years have included innovations in curricula and teaching strategies. Such innovations incorporate concepts novel to medical education, and include reflective practice, experiential learning, and social cognitive learning theory.2–4 These theories share a focus on helping adult learners adopt new perspectives and behaviors through a cycle of practice and reflection. In parallel with these developments has been research on medical culture and context, now commonly called the “hidden curriculum.” The hidden curriculum consists of “commonly held understandings, customs, rituals, and taken-for-granted aspects of what goes on in the life-space we call medical education.”5 Examples abound, including inappropriate humor and language or institutional policies and practices, many of which may undermine even the most well-designed efforts to enhance professionalism, cultural competence, and communication.6 Hence, the hidden curriculum stands as an important barrier to progress in the formal curriculum in these areas. This edition of the Journal contains several articles which, when taken together, shed new light on the choices we educators face when teaching communication skills, fostering humanism, and instilling professional values. Buchanan et al. implemented a 2-week rotation in homeless health care that combined experiential learning with time for reflection. Through content aimed to strengthen those altruistic feelings present in residents, this curriculum taught communication skills that helped change the context of care toward these patients.7 Margalit et al. describe a study of practicing physicians, comparing a didactic and a reflective method to enhance the “biopsychosocial” approach to patient care. The didactic method consisted of reading assignments, lectures, and group discussions. The reflective method consisted of reading assignments, small group discussion, Balint groups, experiential learning, and role-play exercises. The researchers found that physicians who participated in the reflective teaching approach had improved communication skills, decreased cost of care, and improved patient satisfaction compared with faculty participants who had been exposed to the didactic curriculum.8 This study highlights the commonly held notion that communications curricula that include activities for reflection will ultimately be more successful, because the reflection aspect may be stimulating learners to examine and challenge their own assumptions about “how things ought to be”—assumptions that have been molded and shaped by the hidden curriculum. Three articles describe effective teaching interventions at the medical student level. Haist et al. report an intervention with third-year medical students that utilizes standardized patients and coached practice, feedback, and time for reflection to teach HIV and sexually transmitted disease counseling. Students who received the intervention improved their history taking and counseling skills compared to control students.9 Brown et al. describe an intervention to improve tobacco cessation counseling that included skills training and reflection. Students were encouraged to be responsive to emotions surrounding tobacco cessation and to work on rapport-building skills and cross-cultural communication skills in the context of smoking cessation. These students increased their tobacco cessation counseling, and translated their new skills to many other areas of counseling including diet, alcohol, medication adherence, and safe sexual practices.10 Torke et al. engaged students in end-of-life skills training via use of a readers’ theater and role-play exercises, and found the reflective tone of the workshop increasing self-reported application of new skills.11 Each of these studies demonstrates the feasibility and effectiveness of reflection, role play, and emotional involvement in teaching important clinical skills to medical students in the first and third years of training. By starting early and reinforcing later, such behaviors may be more likely to be incorporated into practice styles. Repeated, related training, throughout the seven or more years of a physician's training, may also help change institutional culture and break down the barriers of the hidden curriculum. In addition to work on communications skills training, two articles in this issue of the Journal describe attempts to directly address the hidden curriculum itself. Suchman et al. describe a school-wide effort to improve the culture of the Indiana University School of Medicine.12 Never before has such a widespread effort been made to “re-form” a medical school, including its procedures, attitudes, assumptions, and “common sense” messages. Also novel are the methods being employed for change, focusing on the best and brightest parts of the institution and finding ways to bolster these, rather than “rooting out” problems to be eliminated. If successful, Indiana University will become the benchmark for how to improve curriculum through attention to the context that exists around curriculum. In a second article, Smith et al. report a novel approach to addressing the hidden curriculum via use of a cultural consensus analysis tool in an outpatient clinic. Their tool identified value differences between faculty, residents, staff, and patients. An analysis of these value differences allowed them to develop specific interventions to improve clinic function.13 This study confirms the idea that attending to the cultural environment and context of educational interventions should involve both the learner and the teacher and allows the learner-teacher interaction to become a rich and explicit part of the educational intervention. This reflection ties together the learner, the teacher, and culture, and can establish a new environment for future relationships and educational experiences. Ultimately, the papers we have highlighted tell a simultaneously sobering and hopeful collective tale. Curricular efforts in patient-physician communication, professionalism, and cultural competence (and, we suspect, many other topics as well) do not exist in a vacuum. Rather they exist in a contextualized environment that may help or hinder the curricular goals. This recognition also fuels the opportunity to enhance curricular goals through purposeful attention to the “hidden curriculum,” adopting the mantle of organizational change. As educators, our job does not stop with learning goals and objectives or pedagogical methods. Rather, we must also look at the context and culture in which we teach, and make adjustments for that context if we are to be successful. As education researchers, we need to focus more effort on understanding and developing methods for intervening upon the hidden curriculum. As individual course directors and medical teachers, we must realize that those times when we are not teaching may be the most powerfully “taught” times of all. The approaches outlined in the papers in this edition make us hopeful that the “new revolution” to address the hidden curriculum and advance teaching of communication skills, humanism, and professionalism is well underway.