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Acad Med. 2020 Feb 11. doi: 10.1097/ACM.0000000000003193. [Epub ahead of print]

Beyond High Stakes Testing: Learner Trust, Educational Commodification, and The Loss of Medical School Professionalism.

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F.W. Hafferty is professor of medical education, Division of General Internal Medicine and Program in Professionalism and Values, Mayo Clinic, Rochester, Minnesota; ORCID: B.C. O'Brien is professor of medicine, Department of Medicine, and education scientist, Center for Faculty Educators, University of California San Francisco School of Medicine, San Francisco, California. J.C Tilburt is professor of medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota.


With ever-growing emphasis on high-stakes testing in medical education, such as the Medical College Admission Test and the United States Medical Licensing Examination Step 1, there has been a recent surge of concerns on the rise of a "Step 1 climate" within U.S. medical schools. The authors propose an alternative source of the "climate problem" in current institutions of medical education. Drawing on the intertwined concepts of trust and professionalism as organizational constructs, the authors propose that the core problem is not hijacking-by-exam but rather a hijackable learning environment weakened by a pernicious and under-recognized tide of commodification within the U.S. medical education system. The authors discuss several factors contributing to this weakening of medicine's control over its learning environments, including erosion of trust in medical school curricula as adequate preparation for entry into the profession, increasing reliance on external profit-driven sources of medical education, and the emergence of an internal medical education marketplace. They call attention to breaches in the core tenets of a profession-namely a logic that differentiates its work from market and managerial forces, along with related slippages in discretionary decision-making. The authors suggest reducing reliance on external performance metrics (high-stakes exams and corporate rankings), identifying and investing in alternative metrics that matter, abandoning the marketization of medical education "products," and attending to the language of educational praxis and its potential corruption by market and managerial lexicons. These steps might salvage some self-governing independence implied in the term "profession" and make possible (if not probable) a recovery of a public trust becoming of the term and its training institutions.

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