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Eve Purdy

Sat, 02/16/2019 - 18:50

Dr. Archer,

Thanks for this fascinating read. I love a deep dive and a bit of mental creativity around what might be.

As an anthropologist, I cannot help but see the relevance of a few key theories as they relate to the problems you raise but also in the barriers to solutions.

Cultural compression: This theory suggests that there are times in medical education during which the values and beliefs of the profession weigh most heavily on learners. During moments of cultural compression, those values and beliefs are transmitted and incorporated into the identity of the individual being indoctrinated. The quintessential period of cultural compression is assessment. When we assess people, particularly in a high-stakes setting, we are signalling to them what we think is most important. If we value, as you suggest, physicians that are available/affable/able, then we must really ponder whether current assessment methods – particularly high stakes exams- are in line with those values. If not, then we earnestly risk a cultural transmission towards alternate set of values and beliefs that may not be representative of the kind of doctors we wish to create. I venture that the consequences of this cultural signalling go far beyond the personal wellness of residents for 6-9 months before the exam and wasted time away from the bedside. In my mind, the strong cultural messaging to residents is that knowledge (not availability/affability/ability) is the most important aspect of our job and is the marker of your worth as a physician – and whether we like it or not this value will stick throughout a career. People, who have incorporated that value, then go on to be the next generation of teachers/educators/examiners/medical leaders…and the culture propagates. CaRMS also acts as a consequential moment of cultural compression but I’ll let you explore the cultural signalling of that on your own!

Belonging: The idea that you raise about “learning locally”” just makes so much sense from the perspective of an anthropologist. Humans crave belonging. When they feel that they belong they are more likely to take interpersonal risks (often a necessary step on the path to learning) and they are usually happier. I’ve written about the importance of belonging in medical school before here. The new reality of away rotation after away rotation is not only a threat to the bank account but it also systematically threatens belonging which comes with serious psychologic and educational consequences that we as a community have not only accepted but endorsed and facilitated.

Why is all this (the electives, the matching process, the exams) so hard to change???

Power: There are so many people and organizations with vested interest, and now power, in the process. And so, we end up with the “horse by committee” you presented. The problem is, power is rarely surrendered. Ask any individual from any one of the groups that has power at stake, and I am sure they would agree with some of your suggestions – but not those that relate to reducing their positioning in the process. Each part of your quartet requires stripping power or perceived power from somebody (either almost imperceptibly or overtly) and that is not an easy task…As Dr. S outlines, these changes require consensus from a huge number of stakeholders, all with varying amounts and types power….

I really only offer some anthropologic perspective and don’t offer any solutions, sorry. But I do want to thank you for initiating a conversation which is often a first step on the path to understanding.


Eve Purdy
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