Faculty Development

Crossing the Patient-Centered Divide:
Transforming Health Care Quality Through
Enhanced Faculty Development
Richard M. Frankel, PhD, Florence Eddins-Folensbee, MD, and Thomas S. Inui, MD, ScM

Abstract
In the report “Crossing the Quality
Chasm,” the Institute of Medicine asserted
that patient-centered care is one of the six
domains of quality. In this article, the
authors consider how the patient- and
relationship-centered components of
quality can be achieved in all aspects of
medical care. They suggest that faculty
development in three key areas—mindful
practice, formation, and training in
communication skills—is necessary to
achieve patient- and relationshipcenteredness.

In “Crossing the Quality Chasm,” a
1

widely cited and influential 2001 report,
the Institute of Medicine (IOM) asserted
that patient-centered care is one of six
domains of quality in medical care. The
absence of patient-centeredness in the
physician–patient relationship, the IOM
stated, is associated with outcomes such
as lower patient satisfaction, poorer
adherence to medical recommendations,
less well-controlled blood pressure,
higher glycosylated hemoglobin A1c, and
greater propensity to sue for medical
malpractice in the face of an adverse
event. Although definitions of “patient-

Dr. Frankel is professor of medicine and geriatrics
and senior research scientist, Regenstrief Institute,
Indiana University School of Medicine, and senior
scientist, Center for Implementing Evidence Based
Practice, Richard L. Roudebush Veterans
Administration Medical Center, Indianapolis, Indiana.
Dr. Eddins-Folensbee is associate professor of
psychiatry and behavioral sciences and senior
associate dean of admissions and student affairs,
Baylor College of Medicine, Houston, Texas.
Dr. Inui is president and CEO, Regenstrief Institute,
Sam Regenstrief Professor of Medicine, and associate
dean for health services research, Indiana University
School of Medicine, Indianapolis, Indiana.
Correspondence should be addressed to Dr. Frankel,
Center for Implementing Evidence Based Practice,
Richard L. Roudebush VAMC, 1480 W. 10th St.,
Indianapolis, IN 46202; telephone: (317) 988-4000;
fax: (317) 988-3222; e-mail: rfrankel@iupui.edu.
Acad Med. 2011;86:445–452.
First published online February 21, 2011
doi: 10.1097/ACM.0b013e31820e7e6e

Academic Medicine, Vol. 86, No. 4 / April 2011

The authors first review the philosophical
and scientific foundations of patientcentered and relationship-centered care.
They next describe and provide concrete
examples to illustrate the underlying
theory and practices associated with
each of the three faculty development
areas. They then propose five key areas
for faculty development in patient- and
relationship-centered care: (1) making it
a central competency in all health care
interactions, (2) developing a national
curriculum framework, (3) requiring

performance metrics for professional
development, (4) partnering with
national health care organizations to
disseminate the curriculum framework,
and (5) preserving face-to-face educational
methods for delivering key elements of the
curriculum. Finally, the authors consider
the issues faced in faculty development
today in light of the medical education
issues Abraham Flexner identified more
than a century ago.

centered care” vary, almost all indicate
that patients should be partners in their
care and that their values, attitudes, and
preferences should be considered in
making medical decisions.

Relationship” as a new section of the
journal:

In this article, we review the philosophical
and scientific foundations of patientcentered and relationship-centered care
and suggest that faculty development in
three key areas—mindful practice,
formation, and training in communication
skills—is necessary to achieve patient- and
relationship-centeredness. After providing
concrete examples of teaching methods
in these three areas, we offer five
recommendations for faculty development.
Finally, we examine the link between
patient-centeredness and the medical
education revolution prompted by
Abraham Flexner more than a century ago.
In Flexner’s day, the prevailing view was
that physicians should remain detached
from patients so as to maintain an
“objective” stance. Current concepts of
communication and quality challenge
that physician-centered view of the
patient as a specimen to be studied, and
instead suggest that patients and
physicians mutually influence one
another during the context of giving and
receiving care. Richard Glass,2 deputy
editor of the Journal of the American
Medical Association, captured well this
shift in emphasis in his 1996 editorial
introducing “The Patient–Physician

The patient–physician relationship is the
center of medicine [italics added]. As
described in the patient–physician
covenant, it should be “a moral enterprise
grounded in a covenant of trust.” This
trust is threatened by the lack of empathy
and compassion that often accompany an
uncritical reliance on technology and
pressing economic considerations.

Foundations of Patient- and
Relationship-Centered Care

The contemporary use of the term
“patient-centered care” has its roots in
the work of Joseph Levenstein, a South
African family physician interested in the
effects of family, community, and culture
on care processes and outcomes.3
Levenstein’s ideas concerning the social
and psychological factors affecting
patient behavior were of particular
interest to Ian McWhinney,4 whose 1986
essay “Are we on the brink of a major
transformation of clinical method?” was
influential in promoting a philosophy
that expanded the physician’s role to
include dynamics such as “finding
common ground” with patients as a
fundamental precept for successful
practice. McWhinney and his colleagues
in the University of Western Ontario’s
Department of Family Medicine have
since conducted a series of outcomebased studies documenting the

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Faculty Development

effectiveness of the patient-centered
clinical method.5,6
A more recent expansion of the patientcentered care model is the concept of
relationship-centered care.7 Whereas
patient-centered care focuses on patient
behavior, relationship-centered care
considers relationships to be vital to
medical care, research, and education. It is
based on four principles: (1) Relationships
in health care ought to include not only the
role but also the “personhood” of the
participants, (2) affect and emotion are
important components of these
relationships, (3) these relationships occur
in the context of reciprocal influence, and
(4) the formation and maintenance of
genuine relationships is morally valuable.8
By conceptualizing the relationship as
the smallest unit of measure,
relationship-centered care focuses on
the communication and interactional
processes through which patients’
needs are established and addressed
within the physician–patient
relationship. In terms of medical
education, relationship-centered care
promotes curricula that build on
self-awareness as well as on key
relationships with patients, their family
members, other health professionals,
the community, and society.
The biopsychosocial model developed by
George Engel, an internist with interests
and training in psychiatry, is critical to
understanding contemporary patientand relationship-centered care models.
Engel’s influential 1977 article, “The need
for a new medical model: A challenge for
biomedicine”9 (and other publications10,11),
set the stage for much contemporary
thinking about the physician’s expanded
role as an active participant in, rather
than a “detached observer” of, the
medical encounter. Engel and his
followers have documented the intricate
sets of interrelationships that exist within
the biopsychosocial framework and their
effects on processes and outcomes of
care—for example, the effects that stress
at the societal or cultural level can have
on immune response at the cellular
level.12
Fostering Patient- and
Relationship-Centeredness in
Physician–Patient Interactions

Inherent in patient- and relationshipcentered approaches is the idea that

446

establishing and maintaining healing
relationships is central to delivering highquality health care and requires the
physician to have a deep knowledge of
self. Therefore, professional development
of self-awareness skills is crucial to ensure
that physicians provide patient- and
relationship-centered care, whether they
are responding empathetically to a
patient’s statement of suffering or
considering their own sadness in
delivering bad news to a patient.
Researchers have shown that three
educational approaches to self-awareness
promote patient- and relationshipcenteredness in physicians and trainees:
mindful practice,13,14 formation,15 and
training in communication skills.16,17
Below, we describe each of these
approaches and provide an illustration
of the way each can be taught.
Mindful practice
Broadly speaking, mindfulness is a form
of reflection that allows a practitioner to
review or reexperience a situation and
learn from it. According to Epstein,14
Mindful practitioners attend in a
nonjudgmental way to their own physical
and mental processes during ordinary,
everyday tasks. This critical self-reflection
enables physicians to listen attentively to
patients’ distress, recognize their own
errors, refine their technical skills, make
evidence-based decisions, and clarify their
values so that they can act with
compassion, technical competence,
presence, and insight.

Importantly, mindfulness incorporates a
nonjudgmental stance, one of curiosity
rather than evaluation. In this respect,
mindful practice has much in common
with the philosophical stance of
phenomenology, which asks how we
know what we know, not how we judge
it.18 Schoen19 introduced an early
application of the concept of reflection
in professional practice based on his
observations of how reflective practitioners
in “performing fields” went about their
work.
Mindfulness involves bracketing different
types of knowledge that are relevant to
professional practice. (Bracketing refers to
suspending one’s beliefs and judgments
to understand their underlying
presuppositions and assumptions.) These
types of knowledge include explicit
knowledge, which consists of facts and
logical relationships, and tacit knowledge
(what Polanyi20 referred to as “personal

knowledge”), which consists of internal
experiences, feelings, beliefs, know-how,
and deeply held values. In an educational
setting, explicit knowledge is what
trainees learn formally in the classroom;
it is easily translated into evidence-based
practice guidelines, for example. Tacit or
personal knowledge is what Hafferty and
Franks21 referred to as the informal or
“hidden” curriculum; it is learned from
observing and modeling the behaviors
of others outside the classroom. The
mindful physician reflects and calls on
both types of knowledge in promoting
patient- and relationship-centered
clinical practices.
Teaching mindful practice. One model
for teaching mindful practice is the
five-day intensive course in medical
interviewing skills that the American
Academy on Communication in
Healthcare (AACH) has offered for the
past 25 years, sometimes referred to as
the Lipkin model.22 The AACH course
includes didactic lectures and workshops,
individual and small-group practice
sessions with feedback on bedside and
clinic interviewing skills, personal
awareness (PA) groups, and project
groups. Personal journaling is
encouraged. The goal of the skills
component is to expose learners to
patient- and relationship-centered
interviewing techniques that have been
shown to improve outcomes, such as
opening and setting an agenda for the
visit, eliciting the patient’s perspective,
demonstrating empathy, and testing for
patient comprehension. Groups of four
to six attendees work on these skills with
two faculty facilitators who are trained in
teaching communication skills, small-group
dynamics, and giving effective feedback.
The PA groups operate in a Rogerian,
nondirective style. The facilitator does
not establish an explicit agenda but,
rather, describes ground rules for
confidentiality and the time at which the
session will end. Two skills groups and
their facilitators combine to form a PA
group (8 –10 participants, 4 facilitators)
that remains the same throughout the
week. PA groups meet daily, immediately
before or after skills groups, for two to
three hours. Typically, PA groups raise
deep personal and interpersonal issues;
some are related to the skills group
sessions, and some focus on larger issues
of clinical practice, burnout, balance,
loss, and grief.

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Insights from this method. The AACH’s
method of pairing skills practice with PA
and journaling to teach mindful practice
can lead to dramatic insights.23 For
example, a female physician who has
difficulty interviewing a male alcoholic
patient during a skills session may,
during her PA group, describe growing
up with an alcoholic father who
was loving when he was sober but
emotionally and sometimes physically
abusive when he was not. Although
a connection between these two
experiences may not seem obvious to the
participant, by reflecting in a small group
and then journaling about the experience,
she may gain the insight that her skills
difficulty is a result of her projecting her
own family experience onto her patient.
Having made the connection, the
participant can “process” it both in
subsequent skills sessions and PA groups
as well as through journaling. This
process of increasing mindfulness and
personal growth as experienced by
participants in AACH courses has been
described elsewhere.24 Further, a recent
community-based trial of mindfulness
training showed positive results with
regard to physician burnout, empathy,
and attitudes among primary care
physicians.13
Formation
A number of authors have described the
changes that take place as individuals
move from novice to expert,25 or from
trainee to professional.26 These stages as
well as the processes of professional
enculturation in nursing and medicine
are well described in the literature.27,28
Less studied, but no less important, is
the relationship between professional
socialization and the quality of care that
health care professionals deliver.
Over the last decade, accrediting bodies,
educators, and policy makers have shown
renewed interest in promoting and
educating health care providers about
professionalism and professional values.29
A variety of reasons have been put
forward to explain this. Most scholars
agree that a sizable number of physicians
have become demoralized by the focus on
medicine as a business, pressures on their
time, and a general erosion of trust and
respect for physicians; as a result, they
desire a return to first principles of
the profession.29,30 Additionally,
unprofessional behavior during medical
school has been identified as a “missing

Academic Medicine, Vol. 86, No. 4 / April 2011

link” in predicting who will have
disciplinary actions brought against
them by state medical boards.31 All this
adds up to a burgeoning literature on
defining and assessing medical
professionalism.32,33
How educating for professionalism might
lead to greater patient- and relationshipcenteredness is an interesting and
complex question. From a pedagogical
point of view, the challenge is how to
teach professional values in relationships
at multiple levels across the medical
school curriculum and culture. As noted
by a number of authors,34,35 much
teaching and learning about
professionalism and professional values
occurs through the “hidden” and informal
curriculum. As summarized by Inui and
colleagues,36 learners typically move from
• being focused on the formal to being
focused on the “informal curriculum”
(from noting what we say to noting
what we do);
• being open-minded and curious to
being test-driven and minimalistic,
focused only on what they need to
know to pass examinations;
• being open-hearted and idealistic to
being well defended and
closed-minded;
• being altruistic to cynical, concluding
that medicine is a field in which one
must say one thing and do another;
• being empathic to being task-driven,
focused less on the patient’s experience
and more on getting their own work
done;
• being confident to being uncertain in
their capacity for moral reasoning.

The extent to which patient- and
relationship-centered interactions are
manifest in the environment in which
students are immersed is highly variable
from one institution to another,
suggesting that there are likely “best
practices” that medical educators could
harvest for teaching purposes.37
Strategies to teach trainees. One of the
best ways to teach trainees professional
behavior and role recognition is by using
what psychologists call parallel process to
create and assess learning experiences.38,39
Doing so encourages learners to make
connections among what they are
learning, how they are learning it, and
how it relates to what they see in day-today practice. For example, in teaching

about respect and trust as professional
values in patient care, the educator could
design and employ a parallel trustbuilding exercise so that students
experience in the classroom what it feels
like to be respected and trusted as
individuals. Facilitated learning would
then proceed by moving back and forth
between the students’ experience of being
cared for as individuals and their
responsibility to care for others. In terms
of teaching patient- or relationshipcenteredness as an element of
professional behavior, the educator could
employ a learner-centered approach to
model the behaviors students are
expected to exhibit with their patients.
Parallel processes can also be used to
teach about ethical decision making in
situations of cognitive dissonance.
Classroom exercises and conversations
that anticipate situations in which
students witness their teachers acting
unprofessionally may inoculate students
against cynicism, preventing them from
becoming disillusioned or dispirited.
Strategies to teach faculty. It is also
important to address the hidden
curriculum by teaching faculty to
recognize the complexities of their own
roles as physicians and the culture of the
organizations in which they work. This
might include exploring issues such as
maintaining a balance between home and
work, setting aside time for oneself, and
meeting the service demands of the
profession. Parker Palmer,40 an educator
and social scientist who has written
extensively on this topic, referred to this
as the challenge of “living an undivided
life” and to the process of striving for
wholeness as “formation,” a term
borrowed from educating clergy. Like
mindfulness, formation involves cycles
of reflection on what it means to be a
physician, to be in community, and
to remain true to one’s values and
commitments in the face of competing
demands. It is conceptualized as a
continual process of becoming and is not
thought of as instrumental (i.e., having
an end goal in mind). Formation
activities are particularly helpful in
understanding and dealing with the
spiritual dimensions of patient- and
relationship-centered care.
A faculty development example. The
Center for Courage and Renewal has
been offering programs in formation and
formation facilitator training since

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1997.41 Inspired by Palmer’s work with
primary and secondary school teachers,
its “Courage to Teach” and “Circles of
Trust” programs are designed to help
participants look inward and identify the
role of their subjective experience and
spirituality in their work and personal
lives. These programs have been
expanded to include other professionals,
such as physicians, lawyers, and clergy. A
stated goal of this approach is to help
participants achieve congruence between
their inner experience and the call of
service, thereby leading them to an
“undivided life.”41 In recognition of
Palmer’s work in medicine, the
Accreditation Council for Graduate
Medical Education (AGGME) has given
out 10 Parker J. Palmer Courage to Teach
Awards each year since 2002.
Courage to Lead facilitator training
programs typically involve quarterly 1.5day workshops that are structured
around the seasons of the year, which
provide metaphors for reflection and
dialogue. Courage work is not skills based
in the conventional sense of the term. As
noted above, its goal is not instrumental—
like pairing PA with clinical skills
instruction— but, rather, to create
opportunities for individual reflection
and sharing in small groups. A typical
exercise in courage work is to use a “third
thing” (typically poetry, art, or music) as
an object for reflection and meaning
making. For example, in one exercise,
participants in a large group are asked
to read the poem “The Way It Is,” by
contemporary American poet William
Stafford,42 then they are invited to reflect
on and journal about a few questions (see
Box 1). After journaling, they return
to the large group for an open-ended
discussion of what the process brought
up for them.
In a real-life example, one of us (R.M.F.)
was facilitating a Courage to Lead
training exercise when a general internist
shared that he had recently received a
major promotion that forced him to live
several hundred miles away from his
family, and he could see them only on
weekends. The internist stated that
reflecting on the poem made him realize
that his first commitment was to his
family. As a result of this insight, he said
was planning to resign his new position
to rejoin them full-time (and he
subsequently did). Summing up his
experience with the exercise to his group,

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Box 1
Sample “Courage to Lead” Exercise
and Questions for Reflection
The Way It Is by William Stafford*
There is a thread you follow. It goes among
things that change. But it doesn’t change.
People wonder about what you are pursuing.
You have to explain about the thread.
But it is hard for others to see.
While you hold it you can’t get lost.
Tragedies happen; people get hurt
or die; and you suffer and get old.
Nothing you do can stop time’s unfolding.
You don’t ever let go of the thread.
Questions for reflection
• What is the “thread you follow”?
• How does the thread you follow keep you
from getting “lost”?
• What does the inevitability of “time’s
unfolding” mean for you in your life?
* Source: William Stafford, “The Way It Is” from The
Way It Is: New and Selected Poems. Copyright ©
1988 by the Estate of William Stafford. Used with
the permission of Graywolf Press, Minneapolis,
Minnesota, www.graywolfpress.org.

he said, “I will likely have many jobs in
my lifetime but only one family!”
The link between this type of faculty
development exercise and patient- and
relationship-centered care is the parallel
between being congruent with one’s
values—the importance of family, for
example—and recognizing competing
demands that might challenge or
compromise those values. When viewed
as a model of change, formation is a
particularly powerful tool that faculty can
use to help trainees understand and
balance personal and professional values.
Training in communication skills
If trust, respect, and connectedness are
among the most desirable outcomes of
patient- and relationship-centered care,
then effective communication skills are
the means by which these outcomes
are realized. Recent scholarship has
linked specific communication skills, like
agenda setting and use of empathy, with
specific outcomes of care such as
adherence, propensity to sue for medical
malpractice, and satisfaction with
care.43,44 The landmark IOM report
“To Err Is Human”45 made clear that
communication breakdowns play a major
role in as much as 80% of adverse events.
In terms of medical education, consensus
statements describing effective patient-

and relationship-centered communication
skills, such as finding common ground,
being nonjudgmental, and active listening,
have been published.17,46 Valid and
reliable systems for assessing such
communication skills have been
developed as well.47–49 Also, systematic
reviews of the literature have shown that
communication interventions can
improve patient- or relationship-centered
care.16,50 And, importantly, medical
education research has shown that these
communication skills can be taught,
learned, and put into practice by trainees
and physicians.51–53
Teaching communication skills. Medical
educators have used a variety of
techniques for teaching communication
skills, including simulation with feedback
to improve performance; clinical skills
demonstration, in which an expert
models a behavior and then learners
practice the skills; skills intensives, in
which groups of physicians meet for one
to five days (typically off-site) to learn
and practice skills in small groups; peer
coaching, in which on-site faculty work
with peers to help them improve skills;
interviewing rounds, in which a team of
clinicians goes to the bedside, interviews
an inpatient, and “debriefs” the
encounter; and stop–action videotape
review, in which a facilitator offers
concrete and specific feedback on an
individual’s videotaped interviewing
performance.54 The goal of these
approaches is to help clinicians become
more patient- and relationship-centered
by gaining a better understanding of their
own verbal and nonverbal behavior and
becoming more adept at reading their
patients’ cues, thereby improving
communication and relationships.
An example of communication skills
teaching. Since 1996, Kaiser Permanente
has been using an approach to teaching
and evaluating patient- and relationshipcentered communication skills called
“The Four Habits of Highly Effective
Clinicians”55,56 which is based on a
comprehensive review of the evidence
linking specific elements of clinical
communication with processes and
outcomes of care. The approach consists
of 23 discrete skills that are organized
around four habits of practice: opening
and organizing the beginning of the visit;
eliciting the patient’s perspective;
demonstrating empathy; and sharing
diagnostic information and ensuring

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Faculty Development

patient comprehension at the end of the
visit. The approach attempts to model the
stream of communication that typically
occurs during a visit, recognizing that the
skills that make up each habit do not exist
in isolation but, rather, build on one
another. A valid and reliable coding
scheme for the Four Habits has been
developed49 and has been used to assess
physician skills in a number of different
contexts and countries.57–61
At Kaiser Permanente, the Four Habits
approach has been used to train more
than 10,000 physicians and serves as the
foundation for an array of education
programs. Sustained improvement in
patient satisfaction scores has been
demonstrated, especially for physicians
whose technical skills may be excellent
but whose communication is judged by
patients to be poor.55 Figure 1 shows the
gain scores of physicians with low patient
satisfaction scores who took part in a
five-day “communication skills
intensive” based on the Four Habits
approach during 1998 –2003.55
Communication skills training is especially
useful for practicing physicians: Unless they
graduated from medical school relatively
recently, they are unlikely to have received
formal training in delivering bad news,

using empathy as an efficient and satisfying
clinical tool, and developing functional
partnerships with patients. As with most
clinical skills, there is usually a steep
learning curve. It is therefore important to
recognize and anticipate the time and
commitment necessary for physicians to
learn new communication (or any other)
skills and reach proficiency. The success of
the Four Habits approach at Kaiser
Permanente suggests that, with
organizational “buy-in,” it is possible to
achieve significant improvement in quality
by investing in communication and
relationship skills training.
Recommendations for Professional
and Faculty Development

Many positive changes have taken place
in medical education over the past 100
years, not the least of which is the
recognition and increasing acceptance of
the importance of the “noncognitive”
aspects of becoming and being a doctor.
For example, interpersonal and
communication skills, practice-based
learning, and professionalism have gone
from being suggested to required
competencies that resident physicians
must demonstrate prior to licensure.62
Likewise, medical school faculty are
increasingly being held accountable for

Figure 1 Effect of Four Habits training on Kaiser Permanente physician–patient satisfaction
scores, 1998 –2003. For each of the physician cohorts, aggregated Medical Practice Survey scores
(similar to the Consumer Assessment of Healthcare Providers and Systems survey) showed
statistically significant improvement in the six months following participation in the Four Habits
course compared with their scores six months prior to the training on the five items pertaining to
the patients’ interaction with the physician: skills and abilities, confidence in care, listened and
explained, involvement in decisions about care, and familiar with medical history. From 1998 to
2003, 483 physicians participated in the training. For additional details concerning the study, refer
to Stein et al.55 Reproduced with permission from Patient Education and Counseling. Elsevier
Publishing Company, Amsterdam, The Netherlands. *Statistically significant, P ⬍ .05.

Academic Medicine, Vol. 86, No. 4 / April 2011

the context and culture in which
education takes place. The Liaison
Committee on Medical Education
standard MS-31-A, for example, states
that medical schools must provide the
appropriate context for the development
of expected professional attitudes and
values.63 Finally, the Joint Commission
recently published new guidelines (LD
3.15) that require hospitals and other
health care organizations to have
programs in place to identify and deal
with disruptive behavior exhibited by
practicing physicians.64
In essence, oversight organizations are
calling for a cultural shift, recognizing
that asking trainees to do as we say and
not as we do compromises the quality
of medical education and, ultimately,
undermines their ability to practice
patient- and relationship-centered care.
Whether these changes are the result of a
paradigm shift in conceptions of what
counts as science or the distressing
statistics about patient safety and
satisfaction is a topic for academic debate
and discussion. In the meantime, we are
witnessing many calls for change from
within and many challenges from those
outside the profession.
Following are five recommendations for
faculty and professional development
related to patient- and relationshipcentered care:
1. Establish patient- and relationshipcentered care as a central competency
across the health care continuum. One
place to start is with the admissions
process, which selects the individuals who
will train in our institutions. It seems
reasonable to ask whether there are
admissions processes and practices with a
high probability of identifying applicants
who are likely to develop into physicians
with superb patient- and relationshipcentered skills. McMaster University and
the majority of the other Canadian
medical schools have expanded their
admissions processes beyond the
traditional (face-to-face) interview
format to include mini-OSCE stations for
applicants to complete.65 This and other
techniques for assessing applicants’ values
and attitudes toward patient- and
relationship-centeredness should
continue to be developed, evaluated, and
put into practice. Unlike most European
medical schools, which rely entirely on
paper performance, schools in the United

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States and Canada have the opportunity
to assess applicants before they enter
training. We should take maximum
advantage of this opportunity, as well as
faculty development opportunities, to
find ways to educate students in a broad
range of intellectual and noncognitive
competencies.
2. Develop a national curriculum
framework with input from patients,
health professionals, and other
stakeholders. To train students in a
patient- and relationship-centered care
competency, there must be faculty who
are fully familiar and trained in the
requisite skills that trainees should
embody. This will require development
of a national faculty development
curriculum, with input from a broad
range of stakeholders, including patients,
trainees, and practicing physicians.
3. Require performance metrics in
different domains of education. Linking
elements of professional development in
patient- and relationship-centered care
across the educational continuum (UME,
GME, and CME) will be important to
ensure quality and consistency. Developing
assessment metrics for maintenance of
certification, accreditation, and licensure
will provide external incentives for
achieving and maintaining national
standards for performance in a defined
area of quality.
4. Form partnerships among health care
systems, academic institutions, and
professional organizations to disseminate
and create incentives for adopting the
curriculum (i.e., train-the-trainer model).
The changes we propose will require
health care organizations to form
partnerships to promote patient- and
relationship-centered care principles.
Innovative approaches to disseminating
patient- and relationship-centered
curricula at Kaiser Permanente have
shown promising results and may be
useful as models.55 Additional large-scale
dissemination experiments, tied to
quality outcomes, need to be designed
and tested.
5. Create a patient- and relationshipcentered educational experience that is
interactive and occurs face-to-face over

450

the long term. Although medical
education has begun to take advantage
of digital technology and “virtual”
education, some aspects of training—
including mindfulness, formation, and
learning communication skills—will
continue to require the development of
long-term relationships based on face-toface interaction between learners and
instructors.
Looking Forward

More than a century ago, Abraham
Flexner placed mastery of the content
and methods of the physical and
biological sciences as the highest ideal in
medical education. Today, we would do
well to consider how much has changed
since then in society and in our conceptions
of science. Whereas diseases such as polio,
typhus, and yellow fever now are virtually
unknown in the United States and Canada
and are highly treatable when they do occur
elsewhere, at the turn of the 20th century
the ravages of disease were everywhere and
physicians were limited in what they could
do to cure their afflicted patients. It is not
surprising, therefore, that Flexner and
others concentrated on the biomedical
aspects of medical education, stressing a
focus on the etiology and treatment of
disease. In this regard, the Flexnerian
revolution has been a spectacular success.
One of the consequences of such
unqualified success in the biomedical
domain over the past century, and
something that Flexner could not have
foreseen, is the (relatively) recent
emergence of the patient’s experience as a
significant dimension in medical care.
Engel9 made an important distinction
between disease—a pathological
breakdown of a biological state—and
illness—a social and psychological
response to disease. It is possible to have
illness without disease (e.g., everyday
worry and stress), and disease without
illness (e.g., asymptomatic hypertension).
However, the interplay between disease
and illness has produced fields such as
psychoneuroimmunology as well as
patient- and relationship-centered
approaches to care. While research
and evidence continue to grow, these
approaches are not yet a staple of medical
education.
Part of the distress apparent in medicine
today likely has to do with the fact that
patients, who have never enjoyed a higher

standard of general health, are demanding
more of their physicians than to be diagnosed
and sent on their way. They want to have
meaningful relationships with their medical
providers that allow for discussion of why
one treatment is better than another or
what to do when cure is no longer possible.
It may be painful for medical educators
to learn that our products and we, by
extension, do not enjoy the same status
and acceptance we once did and that
physicians already in the profession are
demoralized by this state of affairs, as
illustrated by their being less willing than
ever before to recommend that their
children follow in their footsteps.66 The
good news in this otherwise discouraging
scenario is that we are beginning to ask
important questions, as the IOM and
others have done, in trying to define
quality of medical care and what it means
to be professional. By beginning with the
outcomes we most desire and asking
which methods will best help us to
achieve them, we are doing what Flexner
did more than a century ago. Faced with
the practical problem of educating
physicians who varied greatly in their
values, abilities, and approaches, he
insisted that physicians be trained to
act in similar ways using similar
methods according to the scientific
evidence before them. Given the
increasing pressures on medical
educators to cover more information in
less time, and the parallel challenge for
practicing physicians to see more
patients in less time, some may wonder
whether there is room in the
curriculum and whether we can afford
the expense of teaching a whole range
of additional patient- and relationshipcentered skills that integrate mind,
body, and spirit. In response, we would
ask, given what happens when patientand relationship-centered skills are
absent, can we afford not to?
Acknowledgments: The authors wish to
acknowledge the assistance of their collaborators
in developing the five recommendations that
appear in this article, including Clarence
Braddock III, MD, Stanford University; Malcolm
Cox, MD, Veteran’s Health Administration and
Harvard Medical School; Anne Gill, DrPH,
Baylor College of Medicine; Martin Hernandez
Torre, MD, Monterrey School of Medicine,
Monterrey, Mexico; Carol Hodgson, PhD,
University of Colorado Denver School of
Medicine; Michael Howe, Howe Associates;
Lynne Kirk, MD, University of Texas Southwestern

Academic Medicine, Vol. 86, No. 4 / April 2011

Faculty Development
Medical School; and LuAnn Wilkerson, David
Geffen School of Medicine at UCLA.
14
Funding/Support: This work was supported by a
writing conference funded by the Medallion
Fund and the Josiah Macy Jr. Foundation. The
conference was entitled “A 2020 Vision of Faculty
Development Across the Medical Education
Continuum” and was held at Baylor College of
Medicine on February 26 –28, 2010.

15

Other disclosures: None.
Ethical approval: Not applicable.

16

Previous presentations: This manuscript was
originally presented at the conference mentioned
above.
Disclaimer: The opinions expressed in this article
are those of the authors alone.

17

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