Education and debate

Trend spotting: fashions in medical education

Joseph K Campbell, course director, MSc in medical education,  Cindy Johnson, lecturer in medical education. 

Academic Department of Medical and Dental Education, University of Wales College of Medicine, Cardiff CF14 4XN

Correspondence to: J K Campbell Campbelljk1{at}cf.ac.uk

This article explores the nature of fashions in medical education and identifies some of the questions about medical education that such fashions raise. What constitutes a fashion in a professional or academic discipline? What do such "fashions" contribute, both positively and negatively, to the development of medical education? What steps can practitioners and academics in medical education take to change a trend into an important step forward in the development of a discipline?

We define a fashion in medical education as an approach to education that is based primarily on social influences, in contrast to approaches based on established educational principles and theories, critically evaluated experiences, or the results of valid research. An analogy is the distinction between fashion in clothes (colour and style) and the quality and functionality of clothing (material and comfort). We chose multiprofessional learning and multimedia computer aided learning as case studies, and we illustrate why each should currently be characterised as a fashion rather than informed practice. Both have received attention internationally in medical curriculum reform. ^{1 2}

	Method

A Medline search was conducted and all available abstracts of articles addressing multimedia computer aided learning (n=258) and multiprofessional learning (n=92) written in 1985-98 were collected. Abstracts were qualitatively analysed to generate categories that could be used to classify each abstract for comparative analysis. Categories included type of publication, relevance of the publication to practice, the presence of and perceived educational rationale informing the publication, and the author's portrayal (as positive, negative, balanced, or neutral) of multimedia computer aided learning or multiprofessional learning. Each abstract was analysed and the results summarised quantitatively to identify issues and trends that might illuminate "fashion" as an influence on practice. The research methodology was informed by Ogawa and Malen's work applying the exploratory case study method to literature reviews.³ This method is used to generate insight into a topic and extend understanding of it rather than to deduce conclusions.

	Multimedia computer aided learning

The combination of different types of media⁴, the power of the computer to control and manipulate media,⁵ and the incorporation of communication technologies to access people and retrieve networked information⁶ are all technological developments that make multimedia computer aided learning appealing. Technological advances can easily disguise what amount to commonsense reasons for pursuing multimedia computer aided learning: multimedia innovations, such as the world wide web and CD Roms, can provide cheap interactive access to the growing body of visual, auditory, and textual information relevant to medical education, thus liberalising the learning process by making it more relevant to individual learners.

Without clear educational reasons for pursuing such commonsense aims, however, multimedia computer aided learning could easily become a massive investment that results in the wasted production of large collections of electronic versions of didactic lecturesa fashionable change in medium with no substantive change in method.

Most publications in Medline that represent multimedia computer aided learning are project descriptions or position statements, rather than reports of research (see table 1); the project descriptions focus on technological developments and lack stated educational reasons or needs for undertaking projects.

Publications that relied on research methodologies (project evaluations, research approaches, and status reports) added little to an understanding of the theoretical and practical application of multimedia computer aided learning in medical education. One explanation for this is a lack of qualitative evidence. Of the 76 (30%) abstracts indicating that a recognised research methodology had been used, only 6 (8%) used qualitative methods. Quantitative methods were dominated by comparisons of multimedia computer aided learning and other teaching approaches such as lectures or teaching small groups. The validity of comparative media research has been criticised by educationalists⁷ because it is difficult to control the many factors that can influence learning, including differences of subject content, teaching objectives, learning activities, instructional context, learning styles,⁸ and symbolic features of media.⁹

A look at the abstracts with regard to their practical relevance (see table 2) shows a focus on teaching. The reasoning that writers used in the abstracts seemed to be primarily based on commonsense approaches (121 (47%) abstracts) to the development of multimedia computer aided learning. References to established educational principles were infrequent (63; 24%) and few abstracts (17; 7%) referred to educational theory. Multimedia computer aided learning is overwhelmingly portrayed as positive (table 3).

Multimedia computer aided learning thus seems to be a development influenced by generally positive, commonsense descriptions of practitioners involved in projects. Research is dominated by quantitative methods of questionable validity and utility. Relevance to practice is centred on teaching, but with minimal consideration of established educational principles or theories.

	Multiprofessional learning

One commonsense view of multiprofessional learning is that health professionals often work together in teams that would be more effective if they understood each other's professional values and roles better. By studying together, they ought to learn more about each other and therefore develop into more effective working teams. Such views should be questioned. Might studying in multiprofessional groups erode professional values or, worse, entrench negative stereotypes that professions hold about one another?

Few articles about multiprofessional learning were reports of research (see table 1); this is not necessarily inappropriate. Descriptions of project experiences are valuable if they contribute to a better overall understanding of project development, implementation, and management or if they indicate common problems and how to avoid them. Well informed position statements can also offer challenges and set standards. ^{10 11}

Of the 21 research based articles, 17 (77%) were quantitatively orientated. This predominance represents a lost opportunity. The power of the positivist paradigm in the medical world is well established, but the medical world needs to wake up to other research philosophies that embrace qualitative approaches.¹²

View larger version (40K): [in this window] [in a new window]   Breaking out of the medical education fashion cycle

Useful measures of the practical value of publications are utility and feasibility.¹³ Most articles on multiprofessional learning focused on either teaching or planning (see table 2), and major components in the educational process such as assessment and evaluation are relatively underrepresented. If innovations are to evolve beyond being fashions and if practitioners are to benefit, such fundamental areas should be explored and disseminated in the medical literature. Commonsense reasoning seemed to underlie half of the abstracts (46); educational principles had been applied in about a third (28, 30%).

In most abstracts multiprofessional learning did not seem to represent the primary or even secondary focus of the article. In 61 (66%) abstracts multiprofessional learning was merely mentioned.

A lack of conceptual clarity about multiprofessional learning was evident in the portrayal of multiprofessional learning: terms such as "multiprofessional," "multidisciplinary," and "interprofessional" were used interchangeably. There was an agreed positive perspective on the value of multiprofessional learning, despite a lack of agreement about what the approach encompasses (see table 3). Multiprofessional learning seems to be a fashion that people describe rather than question. The lack of critical analysis and questioning is remarkable. How can the concept of multiprofessional learning become robust if we don't know what it means, cannot agree its goals, and do not seem able to report the weaknesses and problems encountered and the lessons learnt?

	Discussion

"Common sense" or "hard science" approaches are frequently used in the written representation of two medical education "fashions." Both these approaches are based on an assumption that knowledge exists outside of people and is waiting to be discovered and described. In their review of research investigating the nature of knowledge and knowing, Hofer and Pintrich identify a progression from "lower level" to "higher level" knowledge.¹⁴ The way in which multiprofessional learning and educational media seem to be investigated and reported in the journals indexed by Medline seems to fit with "lower level" knowledge; the transition to the "higher level" is marked by "an ability to construct knowledge in interaction with each other."¹⁴

Active debate is needed for knowledge to evolve in medical education. Writing articles and abstracts is part of professional dialogue, yet this debate is not happening in relation to these two trends in medical education. One barrier to true debate is a lack of conceptual clarity. Authors do not need to be unanimous in their definition of a concept, but they must be clear about their conceptualisation of particular trends or fashions so that other practitioners may understand what they mean. ^{15 16}

Conceptual fuzziness is perpetuated when abstracts and articles are used selectively by academics, researchers, and practitioners to support their arguments when they publish.¹⁷ The more varied the conceptualisation of a fashion, the wider the range of sources of support. So in the short term it would seem there are rewards all round. The oversimplified approaches to educational topics that sustain fashions inhibit the process of conceptual definition and redefinition that is fundamental to the progressive development of concepts in medical education. There needs to be a commitment to break out of "fashion" cycles (figure), to develop concepts previously used as symbolic ornamentation into tools that can advance medical education practice.

Though a "conceptual fog" surrounds problem based learning (PBL), the explicit communication of concepts, goals, and research evidence in this areaeven if they are conflictinghas enabled problem based learning to transcend fashion status. The emergent clarity about the "true PBL genus" Maudsley describes¹⁶ is informed by a process of critical dialogue, argument, and debate around the evidence that is accumulating.

Evidence based medicinal education?
The arrival of evidence based medicine may be seen as a reaction to the prevalence of commonsense justification for practice. Tonelli points out that the scientific approach within evidence based medicine doesn't reach all areas of professional decision making.¹⁸ Research based on contrasting philosophies, it has been argued, needs to inform medical practice.¹²

Conclusion
Multiprofessional learning and multimedia computer aided learning as represented in Medline abstracts between 1985 and 1998 are characteristic of fashions. The general questions raised by the exploration of these two topics need to be followed by analyses that reach both wider and deeper into the literature. Whether the questions raised are characteristic of medical education fashions or of medical education in general requires further and different research than that being undertaken in multiprofessional learning and multimedia computer aided learning.

	Footnotes

   Competing interests: None declared.

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