David J. Schleich, PhD
Although in use for many years in the higher education literature about professions such as medicine, law, architecture, dentistry, and so on, the term “professional formation” continues to befuddle those who encounter it. Our own naturopathic medical educators, as well as medical academics from the biomedical profession, have begun using it more frequently. In fact, the recent Carnegie Foundation for the Advancement of Teaching publication, Educating Physicians: A Call for Reform of Medical School and Residency, incorporates the concept as an organizing filament in their study (Cooke, Irby, & O’Brien, 2010).
100 Years in the Making
As an anchor to any effort to demystify what the term means, we may want to recall that the professional formation related to medical doctors got its kick-start 100 years ago this past spring. On April 16, 1910, Henry Pritchett, the first president of The Carnegie Foundation for the Advancement of Teaching, opened a century of effort in a reengineered approach to professional preparation for medical doctors and for subordinate professions in the allopathic domain. Pritchett was behind the “ambulando discimus” [that is, ‘field work’ analysis and discussion] process that led to the creation of the document known as “Bulletin Number Four” or, more famously as, Medical Education in the United States and Canada by Abraham Flexner (1910). Flexner actually visited in person every one of the 155 medical schools at the time to observe and report on what they were doing and in what kinds of facilities and milieux. He had a model of excellence in mind with which to compare the schools on his itinerary, that being Johns Hopkins University where the foundations of higher education in medicine were well established: formal pre-medical prerequisites, a four-year curriculum with biomedical sciences as its foundation and rigorous clinical education as its signature pedagogy, and these enhanced with easy access by students to teaching hospitals.
We are all familiar with Abraham Flexner’s report, the outcomes of which knocked out two-thirds of the existing 155 medical schools at the time in America and Canada, among them some well-known eclectic and homeopathic colleges (Flexner, 1943, p. 113). The recent work of Molly Cooke, David Irby, and Bridget O’Brien (2010), mandated by the same foundation ten decades later, suggests though that the approach biomedical schools have been taking for the last century needs significant reform. Flexner’s model of standardization and regulation has served the allopathic arena very well the investigators report, but the time has come to shift gears. The urgency communicated in their study is also relevant to what is occurring within the naturopathic medical education landscape.
Reexamining the Mainstream
As Lee Shulman recently pointed out, certain biomedical education theorists, only too aware no doubt of the bruising their profession has taken in terms of credibility and ascendancy in the community since abandoning its social contract half a century ago, and noting, too, how other professional groups are rapidly “forming” and nipping at the guild-like gates of their protected city of entitlement and obligation, conclude that it is time to reexamine what the mainstream Western biomedical system custodians are doing to sustain their dominance, especially in what Baer (2001) labels as the dominative American system of orthodox medicine (Cooke et al., 2010, pp. v-xii; Ludmerer, 1999, pp. 21-25; 371; 387-399). These scholars have been dusting off their higher education and professional formation lenses and looking closely at how the biomedical doctors have, in keeping with the Flexnerian standards which started them down the reductionist path in the first place, “reified the value of ‘seat time’ as a measure of academic rigor instead of looking to students’ actual learning as the real gold standard” (Batalden, Leach, Swing, Dreyfus, & Dreyfus, 2002; Bhandari et al., 2003; Irby & Wilkerson, 2003; Cooke et al., 2010, p. vii). We are in exactly the same boat in the naturopathic medical world. It is increasingly difficult to sustain 30-40 teaching contact hours per week for our students at $350 per credit hour and no public subsidy to keep the lid on student debt!
Threats to Today’s Primary Care
Coupled with this persistent battering of quality and effectiveness, there are other persistent threats to the sustaining of quality primary care in North America. There is a quantifiable maldistribution of PCP (primary care physician) personnel, for example, and a wretched, persistent, pervasive commodifying of health care delivery wherein HMOs and insurers have, some would argue, far too much to say about who gets what kind of care, how often, and with what degree of continuity. However, there is more affecting the bumpy ride of “professional formation” of NDs than the self-interests of multitudes of government, medical, pharmaceutical, insurer, and hi-tech medical equipment provider hands in the pockets and prognoses of patients. Even before our graduates head out to establish their clinical practices or to work in health care facilities operated by government or private enterprise, the curriculum and the ensuing “professional formation” arrangements of biomedicine and natural medicine are lacking, and our students ill prepared to join the profession they have chosen. Shulman suggests three persistent areas of weakness in medical education, which many in the naturopathic medical education field would likely acknowledge: inflexible medical training, excessively long programs, and a lack of learner-centeredness (Cooke et al., 2010, p. 3). The authors argue that there are “poor connections between formal knowledge and experiential learning and inadequate attention to patient populations, health care delivery, and effectiveness” (Cooke et al., 2010, p. 3). His contention that “students lack a holistic view of patients and often poorly understand nonclinical physician roles” resonates with NDs immediately (Cooke et al., 2010, p. 3).
Whatever the culprits, “the pace and commercial nature of health care,” the grave consequences of graduate choice of procedural specialties rather than primary care, or the sundered social contract to which Ludmerer alludes (1999), formation of a professional identity acceptable to the orthodox MDs and, for their part, the heterodox NDs, is an important, almost singular priority. The scholarship documenting “lapses in professionalism” has demonstrated the link between what occurs in medical school and later professional sanctions by regulatory bodies (Papadakis, Arnold, Blank, Holmboe, & Lipner, 2008; Papadakis, Loeser, & Healy, 2001; Papadakis, Hodgson, Teherani, & Kohatsu, 2004; Papadakis, Osborn, Cooke, & Healey, 1999; Papadakis et al., 2005).
The work of Newton, Barber, Clardy, Cleveland, and O’Sullivan (2008) is also alarming, in this regard, in its revelations of significant declines in empathy and altruism among medical students during their critical, formative years in medical school. Linked to this data, Cooke et al. (2010) warn us “medical education is still squeamish about addressing the aspirational dimension of medicine, specifically the critical importance of inculcating a desire to be more compassionate, more altruistic, and more humane” (p. 30). The literature abounds in admonitions about how “moral development of physicians-to-be is … arrested or regressing” (Branch, 2000; Branch, Pels, Lawrence, & Arky, 1993). Where these deleterious influences on professional formation arise has also been studied at length in recent years. Cooke et al. (2010) report on the following as major variables: the pressures of a competitive learning environment in medical school; the corrosive effects of the informal and hidden curriculum in clinical settings, that is, unprofessional behaviors of team members observed by students; the unwillingness of medical schools and teaching hospitals to take action against unprofessional behavior on the part of faculty and staff who create a hostile work environment; the lack of opportunities for students to reflect on and learn from professionalism issues; and insufficient contact with positive role models who embody the highest values of the profession (Cooke et al., 2010, p. 100).
Professional Formation as a Goal
Compelling then is our need in the naturopathic medical community to bring to the fore of our curriculum and program planning the idea of professional formation as a key goal or aim. Wear and Castellani (2000) have assisted us in this focus by defining professional formation as “an ongoing, self-reflective process involving habits of thinking, feeling and acting” (p. 603). Lave and Wenger (1991) further describe this process as involving the “construction of identities” (p. 53). There is an explicit “reflectiveness” which has to be part of the forming of professional identity and values as our students take shape as naturopathic physicians. The situated nature (as Cooke calls it) of professional formation simply has to be top of mind for our curriculum designers and our faculty and reflected on continuously by these educators and their colleagues on admissions committees and during the measurement and evaluation of learning outcomes. The intersection of foundational science competencies with the applied science and art of naturopathic modalities, strongly supported by outstanding clinical experience, would all have to be concertedly coordinated for professional formation to occur systematically.
Such reflectivity has been written about before. Schön’s work, Educating the Reflective Practitioner (1987) reminds us that what our doctors learn, what they “know,” must be translated into action. Across time, with the right professional formation modeling at the beginning and the right professional formation discipline along the way (including continuing medical education, sustained collegial interchange, and abundant clinical experience), the “knowing-in-action” transforms into what Schön describes as “reflection in action” (Schön, 1987, p. 40). The art and practice of naturopathic medicine, then, aspires to a reflective, incrementally effective pattern of professional life absolutely tied, in turn, to the principles of naturopathic medicine, which lie at the core of the art and science of the naturopathic approach to health promotion. Throughout their careers, NDs will be “forming” professionally, from Schön’s point of view. They learn by doing, they benefit from peer mentoring and the coaching of their teachers, and they welcome reflective dialogue which promotes self-regulated learning, yet another dimension of professional formation for our students and our doctors.
Arnold and Stern (2006) who, elsewhere, summarize well what the formation of professional identity requires:
Building on an essential foundation of clinical competence, communication and interpersonal skills, and ethical and legal understanding, professional formation necessarily extends to aspiration goals in performance excellence, accountability, humanism and altruism (p. 11).
In an era where interest in “integrative medicine curriculum” is strong, and calls for “closer collaboration between conventional medical schools and CAM academic institutions” in development of integrated medicine curricula, the need for clarity about what the graduates of such a collaborative effort would aspire to by way of a professional identity is all the more significant to contemplate (Benjamin et al., 2007, p. 1021).
In the era of the Patient Protection and Affordable Care Act (HR 3590) in the Unites States, when concepts such as “personalized prevention plan services” (Sec. 4103) and incentives are built into a “healthy lifestyles program” (Sec. 4108), and $10 billion is targeted to enhancing Community Health Centers (Sec. 10503), the type of “professional” our schools need to “form” is so aligned with the traditions and values of the naturopathic community, we may see this period as our greatest opportunity in ten decades to expand and develop the profession. Even Section 10407, related to “better diabetes care,” has the role of the ND embedded in its intentions.
David Schleich, PhD is president and CEO of NCNM, former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Other previous posts have included appointments as vice president academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd) and the University of Toronto (PhD).
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