The evolving field of medical education research

Authors

  • Robyn Traynor,

    1. Department of Psychology, McMaster University, Hamilton, Canada
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  • Kevin W. Eva

    Corresponding author
    1. Centre for Health Education Scholarship, Department of Medicine, University of British Columbia, Vancouver, Canada
    • Centre for Health Education Scholarship, JPPN 3324, 910 West 10th Ave., Vancouver, British Columbia, Canada, V5Z 4E3
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    • Tel.: (905) 525.9140 x27241; Fax: (905) 572.7099


Educational research is a unique field of study, in that it must be multi-disciplinary to be successful. At the same time it is susceptible to many of the same insular tendencies that impact upon and limit individual disciplines. The scope of research is broad with frequently debated objectives and the definitions of “good” and “rigorous” research are as diverse as the employed methodologies and theoretical frameworks. The vast number of variables impacting upon human behavior, affecting one's ability to accurately predict an educational outcome, provides another example of the challenges inherent in such work. These issues create a number of difficulties that one must overcome, but they also create an exceptionally rich field in which to work, nudging individuals beyond the boundaries of their primary disciplines and into innovative collaborations and new perspectives. In this article, we present elements from the ongoing evolution of the field of medical education research in the hope of promoting ongoing discussions between those working in that field and those working in the molecular life sciences through which both fields may continue to grow and learn.

CONTEXT

As education research in both molecular life sciences and medical education continues to grow, leaders in both fields seek to promote further development as scholarly and productive fields of study. To that end, we were asked to consider (and write about) the evolution of medical education research and to reflect upon what lessons might be derived that could help advance both fields. We do so cautiously as we are certain that the actual issues and innovations in the two fields will not translate directly in all circumstances, both fields undoubtedly being subject to their own specific challenges and goals. Equally certain, however, is that there are similarities that may yield advantages and allow educational researchers in both fields to build their chosen areas of study to a higher plateau. So, though we anticipate that every field must experience its own distinct growing pains, we offer this history and perspective on medical education research as a point of discussion to facilitate cross-talk between our fields in the hope that we may more successfully learn from one another. Space constraints prevent us from going into great detail and we do not profess to be expert in all that molecular life sciences education research has to offer, but we will reference thoroughly should anyone wish to build further understanding of the challenges and history of medical education research for the sake of drawing their own comparisons between the fields and generating novel insights.

With that as background, the most fundamental thing to note about educational research in any field is that, it is a challenging enterprise rife with unique complexities and considerations. Such statements can be made about any number of fields, but unlike molecular life sciences (for example), everyone has experience with education and, as such, we all have developed intuitions about what works and what does not. Those intuitions make it easy to assume that educational research is accessible to all, but in actuality, it should not be seen as an easy route to more publications in which one can engage without methodological training, educational content expertise, and dedicated time. Medical education research has been described tidily as the “critical, systematic, study of teaching, and learning in medicine,” with focus on the “scholarly analysis of the context, processes, and outcomes of all phases of medical education” [1]. Generating a common consensus on all of the defining aspects of medical education research is, however, much harder to accomplish. Its history has witnessed (and continues to witness) considerable debate concerning the form the research should take, the roles it should play, and the audience it should serve [2]. This is in part because medical education research, as a field of study, is informed by many scientific disciplines; the scope of research is broad, the theoretical perspectives variable, and the study designs creatively diverse. In this article, we will highlight aspects from the past and present of research in medical education that we think will be informative in terms of how our field has arrived at its current position. We do so with the hope that readers will recognize that medical education research is itself a work in progress, its future lying beyond explicit prediction [3].

The field's inaugural goal was to improve the quality of learning in medical schools, recognizing the great potential of incorporating basic educational principles to improve medical teaching practices [4, 5]. While this general goal remains central to today's research, it continues to evolve into more specific realms of teaching, curriculum, assessment, program evaluation, education theory, etc. [6] with diversity of scope from the undergraduate classroom through clinical experiences and workplace-based learning/assessment. At the same time, the scope is broadening from an early focus on medical knowledge to focus upon a variety of competencies including professional behavior, patient advocacy, and collaborative interprofessional care [7]. It is this theme of on-going evolution that is central to our article: where we began in medical education research is different from, yet firmly related to where we are now; and more importantly, where we are now will likely prove to be different from where we may go.

THE PAST

The formal inception of medical education research into various medical schools across North America and the United Kingdom began in the 1950s [4, 5, 8, 9]. These early origins hailed from two straightforward ideas: 1) the quality of medical education could be improved; and 2) the expertise needed to achieve improvement extended beyond clinical competence [4]. While these were important building blocks, the field really began to expand in the U.S. in the 1960s, because of a rise in student demand, the students themselves were beginning to insist upon improved assessment and training strategies and the allocation of federal funding for innovations in medical education [5].

Early research efforts typically arose through small-scale collaborations between Schools of Medicine and professional educators. These efforts tended to focus on local program evaluation as individual schools sought to assess the quality and effectiveness of their pre-existing curricula [4, 5, 8]. To do so, the field's pioneers began to venture more broadly into areas of education theory, probing a variety of topics including the link between education and professional competency [10], the interaction between teacher and student [11], and the potential advantages of novel teaching and assessment methods [12, 13]. These activities signified the start of a shift away from reliance on intuition or tradition as the ultimate guiding principles for educational activities toward placing greater emphasis on empirical and systematically collected research evidence [14, 15].

The early leaders demonstrated the importance of including a diversity of perspectives in educational research as individuals came to the field from different disciplinary backgrounds including medicine, psychology, sociology, epidemiology, and statistics. Discipline-based academics began collaborating with the clinicians and educators in the health professions, each group providing alternative and complementary perspectives on issues inherent in teaching medicine and providing a variety of formal research techniques to allow study into the practical problems of the field with increasing rigor [16, 17]. These collaborations among traditionally detached fields were innovations in themselves and laid the groundwork for the even more diverse scope that currently encompasses the field [5].

From these early beginnings came new ideas, new collaborations and early successes that ushered in a widespread acknowledgment of the distinct link between research results and education practice [14]. For example, basic research into expertise acquisition ruled out the previously touted convention of a one-way teacher-to-student transmission of knowledge in favor of greater bidirectional teacher-student interaction [11]. Didactic teaching strategies became supplemented with more self-instructional, problem-based strategies as these latter examples proved equally effective but with greater student/teacher satisfaction [12, 14]. Traditional written examinations made way for more simulation-based assessments as an accurate test of student knowledge and performance [14]. These and other early successes have yielded increasing levels of institutional support with the establishment of formal offices, departments, and centers of medical education research. These centers began as and continue to be diverse in structure, size, and purpose [18]. Examples of highly functioning units are described in a special issue of Academic Medicine, published in 2004. Which (if any) of these groups should now be considered a model for others to uphold depend entirely on the local culture, needs, and desires of the institution. A key decision all new units must face, however, whether implicitly or explicitly is whether their primary aim is to be a world-class research institution or a more local service unit, a classic divide that continues to create tension in some areas of medical education research [19]. A real concern is that confusion regarding the group's (or the field's) mandate and attempts to achieve both goals with limited resources may result in doing neither research, nor service, very well.

THE PRESENT

Currently, medical education research as a field is thriving as it never has before. The majority of medical schools in North America have expressed interest in curricular and/or more general educational reform, dictating a growing need for carefully collected data, and convincing theoretical models [20]. Indeed, internationally there are substantially more medical education journals and more articles submitted to those journals than in years past. There has been a rise in the number of national and international conferences focused on medical education, in the number of established graduate programs geared specifically toward helping individuals develop skills in medical education research, and as a result, a rise in the number of individuals who are well-trained to contribute productively to the field. It goes without saying that quantity does not equal quality, but the simple fact that interest and effort is trending in this direction speaks both to the perceived value of the field and the availability of a critical mass of colleagues.

The upside of this development is that, there is a lot of information to draw upon to help educators and educational researchers develop more sophisticated perspectives on their educational activities. A number of insightful papers reviewing results, trends, and adaptations of medical education research may be of interest to those readers wishing to gain a better understanding of the specific contributions of this field [6, 20–23]. The downside for the individual hoping to embark on a career in education research is that, it is increasingly difficult to track and contribute substantially to a field that is already well established. Many contributors to the educational research community find it difficult to balance their desire to conduct thoughtful and well-informed educational research with their need to fulfill clinical and/or educational responsibilities [19]. This makes the multiprofessional collaboration that was begun in the past even more critical to the success of those who wish to contribute to the field in the present. Simple program evaluations that test the quality of a local training initiative or are uninformed of research that has already been published are less likely to be considered innovative thanks to increasing recognition that studies must be based in a solid conceptual framework [24] if the research efforts are to avoid becoming dispersed, repetitive, un-interpretable, or unable to be used to build more general themes for the sake of strengthening claims to progress [19, 25].

Having said that, medical education research remains a field in which there is considerable debate about its identity and its value. In setting the context for this article, we suggested that medical education research has yet to settle on a simple answer to the questions of what should be studied, how it should be studied, and why it should be studied. We will not present an exhaustive review of these debatable topics but will instead highlight a few issues to shed additional light on the current state of educational research in the health professions. At the core of this debate is the seemingly innocuous notion that began the field (and remains at the forefront): that evidence should be collected to guide decision-making about educational activities. With the diversity of fields and perspectives already described, it likely comes as no surprise that not everyone agrees about what constitutes good evidence. Medical education research is primarily rooted in the biomedical tradition and most of its practitioners to this day have had their professional training rooted in that same tradition. In that world, the goal is often to prove that a particular drug is effective, that a particular therapy works, or that certain pathophysiological mechanisms result in particular disease presentations.

This creates a challenge, because, as Regehr explains it, models adapted from the physical sciences come equipped with pre-fabricated implicit assumptions dictating that “good” research may be achieved by following: 1) an imperative of proof in which we test hypotheses in the search for the right answer; and 2) an imperative of simplicity in which we aspire to straightforward, generalizable and broadly applicable results. These goals prove exceptionally difficult to maintain in educational research because of the enormity of variables that impact upon educational environments and the reality that their interactions can yield different effects [26]. The result is that it becomes highly unlikely that any single answer will provide the correct answer for every student in every context. That is not to say that good, influential research cannot be performed, but that it is important to recognize in doing so that it is virtually impossible to administer education in known quantities with known effects in the way that one can administer a drug [27, 28]. The fact that my workshop yielded beneficial learning outcomes cannot be expected to have a great impact on other educators, as it will be virtually impossible for me to explain and explore every specific aspect of the educational experience. Relevant variables include the content covered, the way it was delivered, my enthusiasm as the instructor, the motivation and emotions of the students, the link between each of those factors and the students' previous experiences with me and with other educational activities. As a result, Regehr argues that we need to move beyond the imperative of proof toward an imperative of understanding by conducting studies that help determine how or why things work educationally rather than simply aiming to prove that they did work. Doing so requires developing systematic and productive programs of research, incorporating expertise and resources from multiple institutions, and utilizing varied study designs to tackle the field's inherent complexities [26].

A corollary to this debate concerns whether the fundamental goal of the field should be to advance theory or provide answers to practical and applied problems [19]. Some argue that the sole purpose of medical education research should be to study the link between medical training and clinical outcomes, providing medical educators with results of practical relevance, such as curricular innovations (e.g., the implementation of simulation- and web-based learning technologies) and performance-based assessments (i.e. the introduction of objective structured clinical examinations or OSCEs) [29–31]. Research goals exclusively dictated by these practical demands greatly restrict the opportunity for theoretical undertakings whereas study of underlying, foundational questions may prove over time to have broader practical applicability [2, 25, 32]. For example, research into why the OSCE provides improved measurement over a single patient encounter (inconsistency in measurement/performance, broadly described as context specificity) yields a more general focus on the value of sampling that is now being taken advantage of in countless ways from improved admissions decisions [33] to work-based assessments [34]. This is a central point, because it determines the mandate of the educational research centers and, as such, will determine where resources are applied. While there has been much energy devoted to the debate, we are not convinced that these two positions are necessarily distinct or irreconcilable. Indeed, Stokes' idea of Pasteur's Quadrant is that basic and applied research should not be seen to fall along a continuum [35]. Rather, Pasteur's research could be seen as ideal in that it served the applied master (e.g., Pasteurization) while building fundamental understanding (e.g., germ theory). Without building fundamental understanding it is difficult to make claims of progress. Without keeping an eye on the practical problems in the field it is difficult to make claims of relevance. This duality makes it impossible to judge the quality of work in a field by the narrow criterion of methodological rigor applied to individual studies. Rather, a field should be judged by the extent to which its accumulation of knowledge is having an impact and whether or not the conversation that governs current thinking is evolving in a fruitful direction [36].

Indeed, the theory or approach that one adopts, may be less important than that one adopts some conceptual framework. Hodges defines “discourses” as the lenses through which we view our world and the models we use to conceptualize our work [37]. In doing so, he points out that there are many discourses that are relevant and used within medical education, even though they may be used without conscious awareness and may not be commensurate with one another. Not all are equivalent in size or emphasis, but each contributes to the overall strength of the field. Issues as fundamental as how one defines professional competence are determined by what discourse one adopts and the very notion of competency, therefore, is defined in “different ways at different times” and for different purposes depending on one's discourse. Hodges highlights the importance of recognizing each discourse as having particular strengths and weaknesses, but that each is required to produce a more encompassing view, as each will lead the field in different and not entirely anticipatable directions [37].

THE FUTURE

As medical education research progresses from a set of small local collaborations to a field that is more global in nature, much of its success can be attributed to the insights and activities of the field's founders. Much should be attributed to the collegiality and open mindedness of those working within the field today. It is these characteristics that enable the field to flexibly adapt to whatever nudges serendipity or discipline-based perspectives deem appropriate when dealing with a particular problem. Unfortunately, as a result, we cannot follow our discussion of the field's past and present with a similarly detailed account of its future. As Irby and Wilkerson have noted, innovations resulting from medical education research are “accelerated” by ever changing environmental trends. They cite the development of a multidisciplinary culture between researchers and health professionals, a new understanding of the science behind learning, advances in technology, a change in population health care needs, and an increased demand for accountability as major catalysts in a broad range of educational transformations from curricular design to assessment strategies [20]. However, which educational transformations may come next cannot be predicted with confidence, as the specific catalysts that will arise cannot themselves be predicted with certainty.

That said, where the field of medical education research should aim is itself a topic of great debate. There are those who, like Todres, et al. [38], suggest that adopting a biomedical model hierarchy of research methods may help medical education research follow in the footsteps of health services research, another field that has grown in magnitude and influence in recent years. There are others, however, who patently disagree, citing fundamental differences between medical education research and health services research [39]. As has likely been made clear, we along with others [2, 37] believe that a strength of medical education research rests in its variety, thereby making it unlikely that any one set of criteria will be generated that can define the strength of (or progress in) the field [36]. In maintaining diverse methodologies and research backgrounds, we can enhance the perspective and scope of the educators and researchers in a way that maximizes the chance that the field will better enable them to think through how to solve the problems they face whatever problems should arise.

We are in equal need of outcomes-based research and more fundamental exploration of the many facets influencing education and practice. As a result, it is not sufficient to study educational issues from a biomedical or mechanical or any single perspective. Rather, it is important to draw on the creative study designs, epistemologies, and theoretical insights from a broad variety of disciplines as collaboration within and between these disciplines will be as essential in moving the field forward as it was in getting the field off the ground. We have argued that any methodological approach can have merit so long as the standards of rigor related to that approach are followed [36].

CONCLUSION

Education research can be a very rich field in which to work as it presents many challenges, requiring individuals within the field to push themselves beyond the boundaries they might otherwise not even notice were they to remain within a particular scientific discipline. Researchers working in this field, as Lee Shulman has said, need to act as commuters, constantly traveling back and forth between the educational field, their home disciplines, and the disciplines of colleagues, while trying to avoid getting stuck in the traffic that can result. In this article, we have attempted to highlight broad elements of medical education research's historical and current practices that are hopefully relevant to thinking about how those working within molecular life sciences education can help engender new educational research activities in that field. More fundamentally, our hope is that this article prompts thought about important similarities and differences between the educational activities in both the basic sciences and the health professions in a way that helps to inform the efforts of both.