The Carnegie Foundation for the Advancement of Teaching, which in 1910 helped stimulate the transformation of North American medical education with the publication of the Flexner Report, has a venerated place in the history of American medical education. Within a decade following Flexner's report, a strong scientifically oriented and rigorous form of medical education became well established; its structures and processes have changed relatively little since. However, the forces of change are again challenging medical education, and new calls for reform are emerging. In 2010, the Carnegie Foundation will issue another report, Educating Physicians: A Call for Reform of Medical School and Residency, that calls for (1) standardizing learning outcomes and individualizing the learning process, (2) promoting multiple forms of integration, (3) incorporating habits of inquiry and improvement, and (4) focusing on the progressive formation of the physician's professional identity. The authors, who wrote the 2010 Carnegie report, trace the seeds of these themes in Flexner's work and describe their own conceptions of them, addressing the prior and current challenges to medical education as well as recommendations for achieving excellence. The authors hope that the new report will generate the same excitement about educational innovation and reform of undergraduate and graduate medical education as the Flexner Report did a century ago.

Clinical supervision requires that supervisors make decisions about how much independence to allow their trainees for patient care tasks. The simultaneous goals of ensuring quality patient care and affording trainees appropriate and progressively greater responsibility require that the supervising physician trusts the trainee. Trust allows the trainee to experience increasing levels of participation and responsibility in the workplace in a way that builds competence for future practice. The factors influencing a supervisor's trust in a trainee are related to the supervisor, trainee, the supervisor-trainee relationship, task, and context. This literature-based overview of these five factors informs design principles for clinical education that support the granting of entrustment. Entrustable professional activities offer promise as an example of a novel supervision and assessment strategy based on trust. Informed by the design principles offered here, entrustment can support supervisors' accountability for the outcomes of training by maintaining focus on future patient care outcomes.

In order to identify the components of knowledge that effective clinical teachers of medicine need, the author carried out a qualitative study of six distinguished clinical teachers in general internal medicine in 1991. Using data from interviews, a structured task, and observations of each ward team, he identified six domains of knowledge essential to teaching excellence in the context of teaching rounds: clinical knowledge of medicine, patients, and the context of practice, as well as educational knowledge of learners, general principles of teaching and case-based teaching scripts. When combined, these domains of knowledge allow attending physicians to engage in clinical instructional reasoning and to target their teaching to the specific needs of their learners. The results of this investigation are discussed in relation to both prior research on teacher knowledge, reasoning, and action and faculty development in medicine.

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or below-standard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.

Research on faculty development has focused primarily on individual participants and has produced relatively little generalizable knowledge that can guide faculty development programs. In this article, the authors examine how current research on faculty development in medical education can be enriched by research in related fields such as teacher education, quality improvement, continuing medical education, and workplace learning. As a result of this analysis, the authors revise the old model for conceptualizing faculty development (preferably called professional development). This expanded model calls for research on educational process and outcomes focused on two communities of practice: the community created among participants in faculty development programs and the communities of teaching practice in the workplace (classroom or clinic) where teaching actually occurs. For the faculty development community, the key components are the participants, program, content, facilitator, and context in which the program occurs and in which the faculty teach. For the workplace community, associated components include relationships and networks of association in that environment, the organization and culture of the setting, the teaching tasks and activities, and the mentoring available to the members of that academic and/or clinical community of teaching practice. This expanded model of faculty development generates a new set of research questions, which are described along with six recommendations for enhancing research, including establishment of a national center for research in health professions education.

Clerkship directors and students recognize many challenges associated with learning and performing in the clerkships. Students' perspectives suggest that these challenges may be more complex than clerkship directors and clinical teachers realize and/or are capable of addressing. The areas in which clerkship directors' and students' perspectives are not congruent point to directions for future research that can guide curricula and teaching strategies.

The learning environment (LE) is an important and frequently discussed topic in the health professions education literature. However, there is considerable inconsistency in how the LE is defined and described. The authors propose a definition of the LE and a conceptual framework to facilitate health professions educators in understanding, studying, and designing interventions to improve the LE. To arrive at this conceptual framework, the authors employed a living systems perspective that draws on various frameworks and theories, including ecological psychology, workplace learning, situated cognition, and sociomateriality theory. The conceptual framework identifies five overlapping and interactive core components that form two dimensions: the psychosocial dimension and material dimension. The psychosocial dimension comprises three components: the personal, social, and organizational. Intertwined with the psychosocial dimension at each level is the material dimension, which encompasses physical and virtual spaces. This theoretical lens can facilitate identifying and analyzing problems in the LE and guide development of interventions to mitigate them. The authors conclude with several practical suggestions for health professions educators, investigators, and editors.

Integrating a curriculum is a complex process. It is differentially understood and experienced by students and faculty, and can refer to instructional method, content, faculty work or synthesis of knowledge in the minds of learners. It can occur at different rates and some subjects are integrated more easily than others. We point to some specific considerations as medical schools embark on curriculum reform.