 Good afternoon. My name is Mark Siegler, and on behalf of the McLean Center for Clinical Medical Ethics and the Department of Medicine, I'm delighted to welcome you to the 21st Annual Kageshaw Memorial Lecture. This slide shows the previous lecturers in the series who really read like a who's who of American medical education. They include people like Bob Petersdorf and Ken Ludmerer and last year's speaker, Darryl Kirch, current president of the AMC. Many of the lecturers on this slide are people who have had academic ties to the University of Chicago, and they include Bob Ebert, Al Tarloff, Jordy Kohn, Dan Tosteson, Arthur Rubenstein, and two of the previous lecturers who were actually in the audience today, Dr. Holly Humphrey and Dr. Joe Kursner. Dean Kageshaw, whose picture I show you again, was a distinguished clinician, a medical researcher on malaria and tropical diseases, and a renowned academic leader and administrator. When Cog returned to the University of Chicago in 1946 after service in World War II, he came back as the chair of the Department of Medicine. Three years later, in 1949, he became Dean of the Division of Biological Sciences, a position he held from 1949 until 1961. During those 13 years, Cog was known nationally as the Dean of Deans. He became the leading spokesperson for medical schools and medical education in the United States. He transformed the AMC from a social club for deans into the great policy and educational institution it is today. Dr. Kageshaw spent two years in Washington as President Eisenhower's special assistant for health and medical education. In 1965, he authored the Kageshaw Report, which was entitled Planning for Medical Progress through Education, a report that provided a medical education blueprint for the next generation. In that 1965 report, Dr. Kageshaw said, quoting, those responsible for medical education, faculty, deans, university officials, and legislators will in decades ahead need to devote careful attention to appraising the needs of society for health care and to develop and implement medical education plans to meet those societal needs. We're so happy that Dr. Kageshaw's three children, Dr. Richard Kageshaw, Carol Govan, and Diane Zink, are able to be with us today for the lecture. Welcome. In 1910, 100 years ago, the famous Flexner Report, authored by Abraham Flexner, whose picture I show you, was published by the Carnegie Foundation for the Advancement of Teaching. This report, as you know, revolutionized American medical education and made the American education system the envy of the world. And now, 100 years later, the time has come to prepare a new report for the next century. Our speaker today is Dr. David Irby. Dr. Irby is the Vice Dean for Education, Professor of Medicine, and Director of the Office of Medical Education at the University of California, San Francisco. Dr. Irby recently directed a national study commissioned again by the Carnegie Commission, which will be published in the next week, and which is essentially the new Flexner Report, which is really, as you can imagine, the Irby Report. A preview of that report was published two months ago in academic medicine by Dr. Irby and his colleagues, Dr. Cook and Dr. O'Brien. And essentially, what they are working on is the 100-year follow-up of the Flexner Report. For his work in medical education, Dr. Irby has received many awards, including the John Herbert Award from the National Board of Medical Examiners and the Daniel Tosteson Award for Leadership in Medical Education from the Harvard Medical School. Dr. Irby is noted for his faculty development workshops that have been conducted nationally and internationally, and he's created a year-long teaching scholars program initially at the University of Washington, later at UCSF, through which Dr. Irby has trained more than 130 scholars in the field of medical education. Dr. Irby will speak to us today on the topic, excuse me, on the topic from Flexner to Tomorrow, a call for reform of medical education from the Carnegie Foundation for the Advancement of Teaching. Please join me in giving a warm welcome to Dr. David Irby. Thank you for that warm welcome, Mark. I appreciate it. It's an honor to be here to share this great event, to recognize the exceptional leadership of Kager Shaw. I came into medical education in 1970, and I was just telling Holly that the person who first hired me was Jack Wenberg, who I see proceeded me in this talk in 2002. So lots of wonderful connections here. But certainly he transformed this great university. He transformed the Dean's Club of AAMC, and he also had a great impact on medical education, per se. What I want to do is look back very briefly at Flexner, my predecessor at the Carnegie Foundation for the Advancement of Teaching, and then forward to our study today and share with you the four recommendations that have come out of our work. Given the fact that this is a CME operation and you are getting credit, I must disclose to you that I have no conflicts of interest, in part because I'm not earning a dime on this book, much to my chagrin, but it is true. And we are absolutely thrilled that it will be out in another week. I finally got a copy of it delivered to my doorstep two weeks ago and was absolutely thrilled. This has been a five-year labor of love, and we're excited to see it spring for it. So if we look back a hundred years at the work that Abraham Flexner did, it's striking that he saw this incredible spread of variability in terms of the medical schools' extent at the time. From small mom-and-pop for-profit medical schools that really, in our estimation, would never be termed medical schools to the very elite university medical schools that actually had high standards and were doing a very good job. He repeated, incidentally, the work that had been done before and by the AMA, Dr. Caldwell had been out and site visited all of those medical schools and had also ranked them into three different levels and groups. But being a membership organization, it was impossible for them to be the hatchet person on it, so they turned to the new Carnegie Foundation and asked them to do the work for them. Those places had, if you could pay the tuition, whether you had a high school diploma or not, you were in, and the curriculum, for the most part, was two years of repeated lectures, same lectures, eight months apiece. You stayed awake, read the syllabus, you were a physician. So his recommendations coming out of that are essentially what we have today, that medical schools should be placed within universities. It should be a scientific-based profession, that there should be two years, well, there should be four years of undergraduate science preparation. There should be two years of basic science, and there should be two years of clinical clerkship before you could become a physician. That model is still the model today, and it is one which has stood us in good stead. It has, as Mark said, created the best medical education enterprise in the world. But a lot has changed in the past hundred years, and we need to be more effective and efficient about our learning enterprise in order to advance the next hundred years. And so I'd like to share with you four of the major themes that will be part of our set of recommendations that will be out next month. I should, before doing that, though, mention that our study is one of five studies, all of which have been published by Josie Bass, and they started with the clergy, engineering, law, nursing, and now medicine, were the last of the five-part series. If you're interested, it's very exciting to read the insights, and, in fact, it was very generative to be at Carnegie with my colleagues in the other studies to see how our work and their work actually overlap. We site visited 14. We didn't get around to all medical schools. We decided that we would look at both UME and GME because from our perspective, the major problem, the major challenge, is clinical education. It's where we're stretched the most and where it is most important. And so trying to figure that out, you have to put UME and GME together. You can't deal with either of them independently. And in that sense, our study is different from any of the others, which were initial preparation for those professions. But after we got through looking at the 14 different medical schools and academic medical centers, we spent about a year immersing ourselves in the learning sciences because we felt like if we were going to make some recommendations for policy about future directions, it should be based not only on the creative innovations that we were seeing in these different medical schools, but we ought to be able to make an argument based upon the best information available, the best evidence available regarding how we learn. And so we spent a lot of time reading in that area. So let me outline the four recommendations. The first one is that we need to focus on learning outcomes or competencies. And if we get really good at that, then we can create a whole lot more individualization of the learning process. So we can cut loose of some of the, you must have X number of months of this and X number of course hours in that, and think about what do we want our profession to be able to prepare for practice and then allow much more creativity and innovation. Second piece of it is that we need to get better at being able to integrate things, to make the same thing count twice. So connecting more tightly, formal knowledge with clinical experience. The best learning occurs when you put those together. The next one is that it's not enough to prepare people for practice today. What we have to do is prepare them so that throughout their careers they can continue to grow, continue to innovate, continue to advance the field no matter what they do. And that means we have to inculcate almost into the DNA of every graduate habits of inquiry and improvement. And the final thing is that we need to focus very much on the professionalism, the values, the humanistic traditions of the profession. And we need to do that consciously throughout time and developmentally. And thus, as we're shaping the identities and forming young physicians, we need to do that in a very conscious and progressive manner. So those are the four. I'm going to share each of those in terms of why those are important and then some examples of what this might mean. So to begin with, we want to standardize on outcomes and competencies. And in order to do that, we need to also think about that in terms of the milestones that one would expect at each level of training. So, for example, UCSF as at many other places, we have now not only established our competencies for four years of medical school, but we also have benchmarks for middle and middle of second year, middle of third year, and what we expect in the fourth year. If we get really good at that, we can then and we will need multiple means of assessing those competencies. But if we get really good at it, that opens up all sorts of opportunities for doing other things with it. It was interesting to me to know that the ACGME, when they envisioned the competencies development process, that they were not saying that at the end of residency training that everybody is supposed to be an expert. We always think in terms of novice to expert. Now what they're saying is they need to be competent. They need to be able to perform in a consistent manner independently and that we say that that's adequate performance for their area of expertise. And that we expect over time that their learning trajectory is going to look like this and that over time in practice they will continue to grow and continue to get better. And therefore we need to think about each level of that trajectory, how are we going to monitor that and how are we going to assure that people not only have their individual expertise in their field but also their general level of competence across competency areas. Again from the ABIM, these actually come from Eric Holmboe. I steal shamelessly from my colleagues but I want to recognize them. You can think about these milestones and the individual trajectory of any particular resident or student as part of that process. And our tasks as we are educating our trainees is to help move them along that trajectory in a manner that meets the benchmarks that we would expect of performance so that when they graduate and they head out into practice they're on the right trajectory for continuous growth throughout their lifetime of practice. So the great thing about thinking about the outcomes is that we can therefore think more creatively about how do we get them there. We can individualize much more in terms of how any one individual might achieve those outcomes because people come to us with wonderful backgrounds. I'm sure your students are just like ours. They come in with PhDs in biochemistry. They come in with PhDs in education. They come in with law degrees. They come in with all sorts of experience and background. And yet we treat them all the same. So why can't we create more pathways? If people reach their benchmarks and reach their areas of competencies, why can't we provide them with more opportunities for other learning experience? Allow them to pursue and work more in other areas. So you're, I forgot what you call it, areas of scholarship or scholarly concentration, scholarship and discovery is very much like our pathways to discovery that provides people with an area of expertise in addition to their MD training, which allows them a new and flexible area of entry into the profession. So what might this look like? If we were going to reflect on this from the perspective of residency training where the typical duration of any rotation is fixed because we've got a manpower issue here as well as a training issue, then what we ought to be thinking about is how do we provide multiple levels of experience and opportunities for that same team with multiple levels of expertise based upon their understanding and their skill and ability areas so that someone who is needing basic clinical experience ought to be doing that. And those that have met the milestones maybe ought to be able to work on systems improvement, managing the deployment of resources. I was in a conversation last week where the CEO of the hospital was lamenting the fact that the time it took from the time you entered the ED to the time you were on the floor, if you had to go that direction, was like five or six hours. So how do you compress that and get it down to something? And why is that? Because the resident has to call the other resident who has to call the other resident who has to call the attending who has to call blah blah blah. Lots of system opportunities here, just lots of them. And field building has to do with wrestling with the really difficult questions of the field and advancing our understanding and working on that, whether that's in research, in systems development and improvement, you ought to be able to allow people some flexibility while still getting the work done. But there's another dimension of this as well. And that we could call linear individualization which has to do with thinking over time and the fact that maybe we ought to be rethinking the structure of the boxes here. So there's a lot of discussion at the national level in both medicine and surgery about what constitutes core and what constitutes fellowships. This is just one of those transition areas. So maybe the core and internal medicine ought to be two years and that the third year you're in primary care, you're a hospitalist or you're in your fellowship and you ought to be able to move on in terms of training. Likewise, if you reach all your competency benchmarks in medical school in three years or three and a half years, why not be able to spend the rest of it either doing research or moving on into an internship where you could double count the time you spend in either way. There's been a lot of experience with that, all favorable. Of course it got killed by our friends and those accrediting agencies, but nonetheless we think it's an idea that we might want to explore in terms of how we might think of this across the continuum instead of thinking always with inside the box. So that has to do with the issue of standardization on the outcomes and then trying to individualize the learning process. The second piece of it has to do with how do in the world do we deal with this increasingly complex world of ours with ever expanding knowledge and do it in the same amount of time or as we're suggesting maybe even in less time and that's where the issue of integration begins to take place. One of the very interesting findings from the learning research has to do with the fact that things get retained in memory much better if you have a patient that you see and then you learn the information in relation to it. It's exactly how we build GME. It's exactly how we build clerkships that is the tight approximation as best we can to both clinical skills and knowledge in relation to the patients that we're seeing. And we need to develop within our learners the capacity for multiple different types of reasoning and the ability to put them all together around patient care. The first is what we prize most in academia. That's the formal knowledge, the best evidence, all of the book knowledge that we try to inculcate with people. And it's not just a matter of getting it inside somebody's head but having them actually be able to use it in relation to the patients that they're seeing. We don't prize as much pattern recognition that comes from seeing many many many patients. It is exactly what the ED docs talk about when they say just tell me one question. Is this person sick or not sick? I don't know what is sick or not sick? Well if you've seen thousands of patients you know instantly whether this one's sick or not sick. It's what comes from lots and lots and lots of clinical experience. And the great thing about the human mind is that over time you tend to integrate both the formal knowledge and the pattern recognition together into scripts, illness scripts that work in terms of teaching. What we almost never talk about is creative and adaptive reasoning. It is the process of imagining a different way of doing things. For example, can you imagine an ambulatory clinic with no waiting room? Who would have ever imagined that that could be possible? But if you engineered it right, you actually could. You could run them right exactly in. If of course everybody showed up on time, always a big issue. But it's that kind of imagining. It's what Disney does so well. It's the capacity to think out of the box, think creatively about a future state which does not exist. And as we think about improvement and innovation and creativity and adaptability, that's the critical ingredient. We need to be training for all three of those. So what might this look like? Well, one of the things it would require is in medical school, we need much more clinical immersion early in relation to the formal curriculum that's going. And we need much more science later, best evidence out into the clinical experience. So it needs a balancing act, if you will. And we're very intrigued with the power of longitudinal integrated clerkships in the third year that are going on in a number of medical schools around the country, including ours, because we have now created a system where the primary characteristic is discontinuity. Nobody is together. Not the attending, not the patient, not the resident, not the student. Everybody randomly gets sorted. And if you think about what is learning about in a practice setting, it's about progressively developing skills. And you do that through deliberate practice with feedback. And when you don't know the person you're working with, it doesn't happen. So you need continuity. We need to find better ways of building that into a system which now has almost zero. So we need to think about that in some way. Pedagogically, one of the intriguing things about blended learning, which is the combination of online learning and in person together learning, is that learning outcomes are better in blended learning than either alone. There is something about the interface and there's something about being able to work independently and accountability within a workspace that enhances it. We think that's a place where we can learn more. And obviously, simulations is another place where you can practice until you get it right. And you can continue to grow and refine as part of that process. And finally, we just need multiple forms of assessment, not so much about what people know, but what they can do. And that requires many different ways of doing it. So what would this look like? This is a pretty classic curriculum. It's what most of us would be comfortable looking at. And Flexner would recognize this with one exception. And that doctoring course that runs through there would have not been part of his experience. But nonetheless, this is pretty much what most medical schools look like. What we're advocating would look, well, you can create it yourself, but this is closer to what we would look like, which is we would want clinical clerkships to start upfront, run in parallel sequence with the integrative sciences, and we want that scholarship and inquiry to run through that as well. And the final year would be, in a sense, an opportunity to individualize the experience, either through a variety of elective experiences, preferably pulled together in some form of scholarship and inquiry, or an opportunity to remediate competencies that weren't fully attained, or, heaven forbid, to actually be able to go on to an internship. We doubt that many students would choose that, but it certainly ought to be a possible if you had a excellent way of assessing competence as part of that. At UCSF, we've been playing with this idea. We figured we have the inside track on the knowledge on this new recommendation. So why not be the guinea pigs to try it? So we have a blueprint for what we are going to be working towards. We have only begun the competency piece of it. But the challenge is, how do you think about having a longitudinal clerkship that runs across? Let's say you had one day a week, and we assigned a first year, second year, third year student, maybe a pharmacy student, maybe a nursing student to a community clinic. And they had a panel of patients that they're responsible for, and they work with them over three years, one day a week, longitudinal experience, a set of core preceptors in that clinic who would work with them. They would create their own curriculum around the patients that they're seeing, and it would develop over three years. Now, the challenge in this model is that if we want students to be able to put faces and experiences to the core content they're studying, then we probably need to push them through some of those specialty clinics as they're learning it. So as they're learning about the heart, why not have them see cardiology patients? Well, that sounds great, except that if you have a class as we do of 150, how in the world do you get 150 students through a cardiology clinic at the same time? The answer is, you can't. So then the question becomes, how could we imagine this happening? So what if we had an upfront sort of preview of what medicine is about a clinical skills bootcamp that sort of got them going? And then we dealt with the curriculum very much in the same way we do clerkships, which is it's random. Everybody does not start on medicine and go to OB and then go to surgery. It's all random. So how about if we create our courses in much more modular style, and they would start in a different sequence, and they would run through it in a different way. And as a result, it means that you can actually put 40 students in the multiple hospitals we have in the specialty clinics as they're going through and learning about that. So that was sort of our breakthrough. And periodically, we'd also want to bring them back to integrate across time in our intercessions to deal with issues that are cross cutting and allow them to continue to pursue their inquiry and discovery aspects. So just one school's thought. On the other hand, I was on an LCME site visit a couple weeks ago with somebody across town from here, I will not name which school, which actually has a program that their design for their new curriculum looks just about like that. I almost fell out of my chair when he showed it to me as a Bravo. That's the way we want to think. So third one, habits of inquiry and improvement. Really, this is the issue of focusing on excellence. And it's the issue of how do we keep people focused, not on minimal standards, but on actually maximal standards. And I have to say that one of the books that we were tremendously impressed with was by the writer and scar to Malian, it's called surpassing ourselves. And they are two authors who of all things are retrititions, they write about writing. And their interest was not in the continuum of novice to expert. It was, why is it that some people get really good and others don't? And after lots and lots of practice. So think about your driving habits, for example, do they get better with more practice? Not necessarily, ask my wife, she will tell you. Or writing, some people get really good at writing and others do not. So what's the difference? And the difference has to do with constantly pushing yourself, it's finding the difficult aspects of the craft or experience, and working at those. It's what professional performers do. They don't practice, for example, a pianist does not practice the whole piece in practice all the time, they work on the pieces, places where they're having the hardest trouble. So if we thought about how we set up deliberate practice, focusing people on the really tough nuts, we could actually get a whole lot better. And if we inculcated those habits, it would be very powerful. Likewise, you don't get better in your craft, if you can't adapt. There's sort of two ways of looking at expertise, there's efficiency, that is, scrutinizing things so they're automatic, and you can just do them very quickly. And there's the adaptive expertise, when the patient comes in that with very complex problems, you can't routinize that, it just takes time. Or it's what happens when the surgeon's in the middle of a case, and the routine is going great, and they're marching along quickly, and then all of a sudden, they have to slow up. Sometimes they slow up even before consciously, they're aware they're doing it. Why? Because it's not fitting the pattern. The key is how do you know when to slow up and when not? And that's part of learning this adaptive form of expertise. So we want to focus people on deliberate practice with feedback. And we also want them to sort of always be asking the question, why? Why are we doing it this way? How can we make it better? And what haven't we thought about in relation to this particular patient? And that happens best, incidentally, back to our good friend Abe Flexner's argument, that happens best in communities of practice, where that is the norm that is always being asked, how can we do this better? And that is what universities are all about, and that's why medical schools are within universities. So again, we saw the level here, the issue is how do we keep that trajectory going up as opposed to flattening out? So part of what they argue for is you have to engage people in studying the difficult questions and issues of our time and of our profession in our skill set. That's not a problem because we see it all the time. And in fact, that's one of the wonderful things about medical education, as opposed to a more abstract intellectual process, there are problems looking at us every single day. It helps to engage them in quality improvement projects of one sort or another, in research and innovations. And then to allow them to pursue areas of interest where they get better, they learn the methods, the analytic methods of improvement and inquiry as part of that process. That's why the scholarship piece becomes so critical. Let's see. I'm hitting the wrong one. Let's go down there. Okay. And the final piece, identity formation. The formation term is one that we actually borrowed from our colleagues who did the study of the clergy, where they talk about how you have to change the identity and form the dispositions and the aspirations to the church community, or faith community of which you are a part. And we think that that maps perfectly onto what we have traditionally always talked about in terms of the values and professionalism, the aspirations of what it means to be a physician. And for us, all four of those are really brought together into this issue of forming their identity, because we want them to aspire to be the best. We want them to be able to connect various roles that they play in various knowledge sources, and we want them to be able to meet the requirements of the profession throughout their lifetime. So it's all about taking on the identity of being a physician. One of the things I love as being Vice Dean is when we do our white coat ceremony at the end of orientation week is you see these kids, that's what they seem to me anyway, these students who look very much like graduate students sitting out there in the audience and we come up and we put the white coat on them and they go back out and they just sort of gradually fill in with white coats. And you can just see them sitting a little taller, recognizing they are total frauds at that point, and yet wanting to take on them the values, the dispositions, the aspirations that that white coat symbolizes. And that's what we're talking about. So we learn it through essentially participating in the community of those who are part of that tradition. We do it by attending Grand Rounds, for example. We do it by going to convocation. We do it by patient care. We do it in the classrooms. It's all about framing them within a community. This is where social learning theory becomes so powerful. But probably equally important, it happens by seeing role models. People you say, I wish I could be as empathic as that person. I wish that I could be like that doctor who at that moment of dying was so gracious, so caring with that patient's family. That's what I want to be like. I wonder how they actually said what they said. And I'll practice the scripts for being able to repeat that. That's how we learn. And likewise, we also see the jerks who we say, I learned from that person. I will never, ever be like that. So you can learn it both ways as part of it. And it's also about being coached and given instruction and getting reprimanded. No, that's not the way we deal with each other. Sort of like when you learned how you sit at the table. No, you don't put your elbows on the table. That's not the way we eat here. Oh, okay. Nobody told me that for no, you don't eat before everybody else has served or all of the cultural things which are part of being in that community, which nobody ever tells you about in Stanley, but you learn in the breach. That's how we learn it. It is nice. However, if somebody can actually take you aside and coach you on that, and say, by the way, here's a better way to do it. By the way, please don't do that again. Try this instead is very powerful. Okay, strategies. We have our ethics courses. I think it's helpful and instructive to know the traditions out of which we come to learn ways of thinking about ethical dilemmas in a reasoned way. And our rituals, whether that's white coat ceremonies or rounds or other things that we do together, again, illustrate the values which we find important in our process. Reflection is a very powerful tool as part of this process. And being able to not only reflect on something, but to be able to bounce it off of what others might view. One of the challenges of learning from experiences, you can learn the wrong things. And unless there's somebody else there who can share with you a very different view of it, I mean, how many of us have been at a meeting or in a situation said something we wish we'd never said. And somebody later says, Oh, by the way, you might have tried a difference. And I said, Well, gosh, I thought it was this way. And they said, No, actually, it was this way. And without them sharing that with you, you have no way to balance those different perspectives. So it's in qualitative research, you'd say it's triangulation, you're looking for different views of the same situation. It's very powerful learning is part of that. Another tool in this is what's called appreciative inquiry. And this is just telling wonderful stories about the very best, what we aspire to be. Indiana University is probably the place that's done the most of this, Tom Inouye and his crew. And this, this has to do if we were in here, we would say, take a minute and write a story about an experience you've had where you've seen somebody do an exceptional job of being carrying compassionate or of challenging the system or whatever it is that we value. And then you collect those and then you share them. You share the very best, what we aspire to be. And that actually changes the culture. Instead of bitching and moaning and complaining and putting each other down and dealing with the worst amongst us, you actually focus on the best. And it has to do with that aspirational framework for what we do. I wouldn't say one other thing, though, there's nothing wrong with sort of dealing with the bottom feeders. You know, it only takes one person in a division or in the OR or in an ambulatory clinic to destroy the culture of that group, right? The critical thing in any organization is the sense of trust that you have with other people. And when that's broken, it makes the performance of the whole very difficult. So one of the things that we instituted, thanks to Maxine Papadakis' work, is that we decided we wanted to identify the worst offenders among us and that there was a really easy way to do it. And that was, we would simply add two items on our student teacher evaluation form. That our students fell out on both their teachers and their residents. And it's just very simple. It says, treated me with respect, treats others with respect. One to five scale. And if you happen to say it's bad, there's an opportunity to write in why and we've even got a drop down menu so you can pick because they're getting pretty predictable. And if you get a one or a two, it automatically triggers an email to Dr. Papadakis. And if you get multiples of those, then she will contact you and say, by the way, you're getting these evaluation form, what's going on? And if that doesn't work, then it gets escalated up the chain of command. And we had one particular group of offending faculty that we had to get the chair actively engaged in. But after I think two to three years of rather corrosive administrative input, they actually turned around. And they're now rated very highly and have stopped doing the negative behavior. So we recommend actually both ends of that focus on the best and the aspirations. But if you need to deal with it administratively as well. Okay, this is absolutely about institutional culture and the things that either make it great or make it not so great. So in summary, we basically said that we think medical education can be enhanced if we focus on the learning outcomes. And then we individualized the learning process. We will get more efficient and more bang for our buck, if you will, in terms of the time that we have, if we can more tightly integrate formal knowledge and clinical experience, that we will get a generation of those who continue to advance the fields if we can inculcate habits of inquiry and improvement. And finally, we need to focus on the values and the aspirations that we all seek the physicians we seek to train. And if we do that, we will actually radically transform the medical education landscape. Thank you.