Focus on performance: the 21 century revolution in medical education.

For centuries medicine was predominantly a tradition-based "trade" until the introduction of science transformed it into an intellectually rigorous discipline. That transformation contributed heavily to the dominance in medical education of the learning of biomedical concepts ("knowing that") over learning how to translate that knowledge into clinical performance ("knowing how"). The recent emergence of performance-oriented educational initiatives suggests, however, that the balance between these two complementary approaches is changing, a change that has been referred to as "the Flexnerian revolution of the 21(st) century." Problem-based learning, learning the practice of evidence-based medicine, and learning to use clinical guidelines are among the important initiatives designed to develop high-level performance in the care of individual patients. Initiatives in which learners acquire skill in changing the performance of care systems are also being widely implemented. These trends have received important formal support through recent changes in residency training accreditation standards. Although it is too early to assess the impact of these initiatives or to know whether they will develop further, medical education is unlikely to reach its full potential unless it successfully comes to grips with the challenges of understanding, teaching, and measuring performance.