F.W. Hafferty is professor of medical education, Division of General Internal Medicine and Program in Professionalism and Values, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0002-5604-7268. 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.
Acad Med. 2020 Jun;95(6):833-837. doi: 10.1097/ACM.0000000000003193.
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.
随着医学教育中高风险测试（如医学院入学考试和美国医师执照考试步骤 1）的重要性不断增加，人们对美国医学院中“步骤 1 气候”的出现表示担忧。作者提出了当前医学教育机构中“气候问题”的另一个根源。作者借鉴了信任和专业精神作为组织结构的交织概念，提出核心问题不是考试劫持，而是一个可被劫持的学习环境，这种学习环境因美国医学教育系统中有害且未被认识到的商品化潮流而削弱。作者讨论了导致医学对其学习环境控制能力减弱的几个因素，包括对医学院课程作为进入该行业充分准备的信任侵蚀、越来越依赖外部以利润为导向的医学教育来源，以及内部医学教育市场的出现。他们提请注意违反专业核心原则的行为，即区分其工作与市场和管理力量的逻辑，以及相关的自由裁量决策中的失误。作者建议减少对外部绩效指标（高风险考试和公司排名）的依赖，确定并投资于重要的替代指标，放弃医学教育“产品”的市场化，并关注教育实践的语言及其被市场和管理词汇腐败的可能性。这些步骤可能挽救“专业”一词所隐含的一些自我管理独立性，并使（即使不太可能）恢复对该术语及其培训机构的公众信任。
