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Rapid Responses: Rapid Responses published:
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Reply to Todres, Stephenson and Jones
- David W Wall, Guy Houghton (21 August 2007)
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Medical Education: Training First
- Muhammad N. Ghayur (21 August 2007)
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Only half a story!
- John E Sandars (21 August 2007)
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There is reason for optimism
- Julian Archer (22 August 2007)
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MMC: help or hinderance?
- Rachel E Owers (23 August 2007)
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Something needs to be done
- Robert K McKinley (23 August 2007)
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On the nature of medical education research
- Samantha Scallan, Olga Zolle (31 August 2007)
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Healthcare education research: Funding and RCTS are both needed
- Mark J Newman (31 August 2007)
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Theoretical rigor? Let's start by making explicit the implicit
- Lynn V Knight, Kieran Sweeney (31 August 2007)
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Pictures are important too
- Stewart Lloyd (10 September 2007)
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Medical Education Research
- Mathew Todres, Anne Stephenson, Roger Jones (11 September 2007)
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David W Wall, deputy postgraduate dean Wesr Midlands Deanery B16 9RG, Guy Houghton
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Dear Editor We read the paper by Todres, Stephenson and Jones with great interest. We were pleased to see the topic of medical education research discussed in the British Medical Journal. We support the premise that best evidence supports what we do in medical education, as in the Best Evidence Medical Education (BEME) movement. While we agree that Medical Education and Medical Teacher are two leading medical education journals, these journals tend to focus on undergraduate studies and are not the only publications accepting worthwhile studies from medical and dental education researchers. For instance, we were very surprised that the authors, from a Department of General Practice, did not mention Education for Primary Care, which publishes much medical education research, although principally with a primary care and postgraduate focus. In addition as researchers concentrating on postgraduate medical and dental education, we would also be looking not only at papers published in Postgraduate Medical Journal and in the dental education journals, but also in the education literature, such as the Journal of Qualitative Research, and Evaluation. In addition, we would be presenting our work at national and international medical education conferences. Again, these were not mentioned. We agree that more needs to be done to foster medical and dental education research. In fact it might have been helpful to point out that ASME (the Association for the Study of Medical Education) held a two day conference on getting more research in medical education, have supported training courses on Research Methods in Education, and commissioned a survey of higher degrees in medical education and their research training content. The call for more funding is to be welcomed: despite having in excess of fifty papers between us published in peer reviewed journals, most of our personal research work is done in our own time and at our own expense (even to the extent of having to purchase SPSS software). We do need to mobilise support for ensuring that the best education for medical and dental students, for doctors and dentists in training, and for continuing professional development, is properly delivered and evaluated. A vigorous medical and dental education research framework could answer some of the questions and establish best practice, provided there is adequate and appropriate funding and editors allow educational articles the profile they deserve. We believe that the BEME movement is already answering some of these questions. Finally, we must comment on randomised trials. The randomised trial is not common is educational research and some would even doubt its suitability altogether in an education and social science framework (Norman, 2003). Reference Norman, G. Results confounded and trivial: the perils of grand educational experiments. Med Educ. 2003; 37(7): 582–584 Professor David Wall and Dr Guy Houghton
Competing interests: None declared |
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Muhammad N. Ghayur, Post-Doctoral Fellow Medicine, McMaster University, St. Joseph's Hospital, L-314, 50 Charlton Ave E, Hamilton, ON, Canada
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This is in response to the article on medical education research by Todres et al.[1]. The authors have shed light on a very important element of scarcity of research in the area of medical education. One reason for this lack of research is due to the lack of people trained to do the meaningful research. Having been trained in Pakistan, UK and Canada, I think that this is a universal problem and it cannot be confined geographically. I have always thought that becoming a faculty member (responsible for research and teaching) by 'default' in a medical school just by completing a Ph.D, is not only injustice to the students but also to the field of education. I also think that educationalist are born rather than made, but the traits can be polished by formal training and skill development. It is then absolutely imperative that both potential and new university teaching staff be imparted organized medical education training. Once people are trained, then automatically they will be more interested not only in becoming effective teachers but also capable researchers. This lack of formal teachers' training is such a big problem in developing countries, like Pakistan, that teaching is the least preferred choice for graduates and only pursued when there is not other alternative. The number of medical schools in Pakistan doubled in 2005 in comparison to 1997 while the number of enrolled students sky rocketed 10 times from 1960 to 1981 [2]. All of these with the same proportion of teachers and teachers’ training programs. Recently, there has been some progress in the shape of organization of training courses and workshops for teaching staff at some of the better private sector medical schools in Pakistan. But still, a lot more is needed. I would though quote the example of McMaster University in this regard. Apart from graduate degree programs in the area of medical education under the supervision of world renowned educationalists, faculty members and graduate students alike have the opportunity to enrol in a number of courses and workshops to familiarize themselves with the theory and principles of medical education. This helps to orient people at a very early stage of their careers about teaching and its requirements. Universities in developing countries can learn from foreign schools, in fact, collaborative efforts can be designed to rectify this. Once quality training is delivered, research and funds to perform this research would follow. [1] Todres M, Stephenson A, Jones R. Medical education research remains the poor relation. Br Med J 2007;335:333-5. [2] Talati JJ, Pappas G. Migration, medical education, and health care: a view from Pakistan. Acad Med 2006;81:S55-62. Competing interests: None declared |
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John E Sandars, Senior Lecturer in Community Based Education Medical Education Unit, University of Leeds, LS2 9LN
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The paper by Todres et al [1] is important for all medical educators since it highlights the need for high quality educational research in medical education. However, the authors only provide half the story since there are much wider issues that need to be debated. The reason for research is to gain an understanding of practice so that it can be developed. The lure of an "evidence based" approach is high but, like evidence based medicine, this notion is not without problems. First there has to be a question that can be answered by positivist research methods (the randomised controlled trial) and this is immediately problematic for many educational interventions which are often complex, with numerous variables that cannot be easily controlled. Second, many of the questions that medical educators have are best researched using qualitative methodology but no mention was made of this in the paper. Overall, it is more likely that research that is relevant to the needs of the user will be taken up and used to improve practice [2]. A quick perusal of any standard book on educational research will easily persuade the reader of the need for research that is of high quality yet uses alternative perspectives, such as action research or ethnography.[3] The quality of the research depends on asking the "right" question and using the most appropriate methodology in a rigorous way. It is the rigour of the methodology that needs to be improved. The important message for all medical educators is that all educational research must be improved, otherwise it will not change policy and practice. The scholarship of medical education has to be equivalent to that applied to clinical practice, [4] but we have to recognise that we are working in a different field which requires alternative research perspectives. [1]Todres M, Stephenson A, Jones R Medical education research remains the poor relation British Medical Journal 2007; 335: 333-335 [2]Sandars J, Heller R Improving the implementation of evidence-based practice: a knowledge management perspective Journal of Evaluation in Clinical Practice 2006 12(3): 341-346 [3]Cohen L, Manion, Morrison K Research Methods in Education (5th Edition) 2001 Routledge Falmer; London [4]Sandars J. McAreavey The scholarship of medical educators: a challenge in the present era of change Postgrad Medical Journal 2007 83: 561 Competing interests: None declared |
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Julian Archer, Clinical Lecturer in Medical Education C313 Portland Square, Universities of Exeter & Plymouth, Drake Circus, Plymouth, PL4 8AA
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Dear Editor Todres et al.’s [1] article raises important issues concerning the funding challenges of educational research in medicine. They are correct to point out these challenges, but I fear in this article continue to add to them by their particular reference to randomised controlled trials. This is perhaps a concerning insight into the continuing positivistic ‘lens’ of the profession within a normative paradigm [2]. It is well acknowledged that RCTs are rarely if ever relevant in educational research [3]. It is this continuing and unnecessary conflict of paradigms that not only impacts on funding but also ethical approval [4]. However positive developments are taking place with the authors quite correctly pointing out the importance of the inclusion of medical education in the research assessment exercise in 2008. It is through academic rigour within the specialty that research will start to become more centre stage in terms of appropriate ethical consideration, funding and mainstream interest and comprehension. There are however some other exciting developments that the authors should have also highlighted. Following the Walport report, a number of new Academic Clinical Fellowships and Lectureships in Medical Education have been awarded. These centrally funded positions support academic careers through the doctoral level and beyond within the new UK training framework. These are exciting opportunities to develop academic educators for the future. The positions are funded similarly to the Clinician Scientist posts within the UK Clinical Research Collaboration and so will require further grants in the longer term. This will require major funders of laboratory medicine to review their research profiles. A second major development has been the formation of the Academy for Medical Educators (AME). The Academy’s overall aims include developing and sustaining medical education as an academic discipline and supporting academic and professional leadership in medical education. Foundation membership facilities are in place and elections to the first Council will commence this autumn. The development of a professional body will greatly help to support the fledgling specialty but ultimately responsibility lies with researchers publishing high quality studies grounded in appropriate methodologies that stand up to critical and often sceptical analysis. Dr Julian Archer julian.archer@pms.ac.uk [1] Todres M, Stephenson A, Jones R. Medical education research remains the poor relation. BMJ. 2007;335:333-5. [2] Douglas JD. Understanding everyday life. London: Routledge & Kegan Paul. 1973. [3] Norman GR. Results confounded and trivial: the perils of grand educational experiments. Medical Education. 2003;37(7):582-4. [4] Pugsley L, Dornan T. Using a sledgehammer to crack a nut: clinical ethics review and medical education projects. Medical Education. 2007;41(8):726-8. Competing interests: I am the holder of a UKCRC Clinical Lecturer in Medical Education at Peninsula College of Medicine and Dentistry. I am a Member of the Transitional Council, AME |
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Rachel E Owers, GP ST1 Queen Alexandra Hospital, Portsmouth, PO6 3LY
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Modernising Medical Careers (MMC) is not assisting in the formation of the "critical mass of educational researchers" proposed by Todres et al [1]. After completing an academic Foundation Year 2 post in medical education, I applied for an Academic Clinical Fellowship (ACF). I was not successful as it became clear at interview that the post was intended for clinical research with no place for educational research. MMC aims to provide a "fully integrated clinical academic career pathway" [2] for educationalists through the formation of ACF and Clinical Lecturer posts. With so few ACF posts in education "critical mass" will take some time to achieve. I plan to pursue my interest in education through other routes. [1] Todres et al. Medical education research remains the poor relation. BMJ 335: 333-335 [2] Academic Careers Sub-committee of the Modernising Medical Careers and UK Clinical research Collaboration. Medically- and dentally-qualified academic staff: reccommendations for training the researchers and educators of the future. March 2005. http://www.mmc.nhs.uk/download/Medically-and-Dentally-Qualified-academic- staff-recommendations-Report.pdf Competing interests: None declared |
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Robert K McKinley, Professor of Academic General Practice Keele University Medical School, Keele University, Staffordshire, ST5 5BG.
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Dear Editor The health education community should congratulate Todres, Stephenson and Jones(1) and the contributors here for reopening the debate on the state of medical education research. I would however like to make an observation and a suggestion. The observation is of disappointment that we are still talking about research into medical education rather than into healthcare education – the adjective ‘health’ has not until now been used by Todres’s et. al. nor any of the contributors here. Given that we work in increasingly multi- professional healthcare and educational environments should we not widen the debate? The suggestion is that we refocus the debate and discuss and promote healthcare education as a healthcare technology amenable to the methods used and with access to the funds available for evaluating healthcare technologies. Could this be the ‘something’ which needs to be done to remediate the problems we face? Reference List (1) Todres M, Stephenson A, Jones R. Medical education research remains the poor relation. BMJ 2007; 335(7615):333-335. Competing interests: None declared |
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Samantha Scallan, GP Education Manager Wessex Deanery, Winchester, SO22 5DH, Olga Zolle
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We cannot disagree with Todres et al [1] that more funding is needed for medical education research and that some areas are under-researched. We would, however, be cautious about some of the other accusations levelled at the current state of play of medical education research in their recent paper. Central to the paper is the charge that current medical education research lacks ‘rigour.’ The argument presented by the authors implies that research conducted using data collection techniques such as observation, surveys and so forth, are ‘primitive,’ and that what’s needed is an injection of ‘greater methodological rigour’ through the wider use of experimental designs, case-control studies, randomised controlled trials, meta-analyses and the like. We do not disagree that there is a role for medical education research that yields generalisable findings through these methods; however the choice of such methods should not be seen as the ‘gold standard’ against which all educational studies are judged. Much good innovative and educationally useful work has arisen from small scale projects, single case-studies and reflective accounts of practice, which tend to draw on the so-called ‘primitive’ methods. To view the field of medical educational research through a lens that categorises it into rigorous or not by virtue of the choice of method is contentious, and poses a false dualism (c.f. Pitts, 2004) [2]. Second, the paper seems to imply that funded studies are somehow more worthy than unfunded ones and that the funding bodies (and publishers) are more likely to be attracted by so-called better ‘quality’ scientific research. We struggle to see the relevance of this point to a discussion on the value of educational research, as ‘meaningful outcomes’ come in many guises, some funded, some unfunded. Indeed, we suggest that underlying the discussion of Todres et al are some VERY BIG, unacknowledged assumptions about epistemology, ontology and methodology which lead them to a position that negates the value of non-generalisable research. Such a standpoint is, in our view, untenable. The nature of scientific research is fundamentally different to the nature of educational research. Todres et al foreground patient outcomes and quality of care as the drivers for research in medical education. We argue that this view lacks insight into the learner’s needs, which form a link in the chain that leads to change in practice. Medical education research is about education and for education [3]. Finally, it’s noted that there is a lack of work on career choice. Much work has been conducted in this area over many years; see for example the work of Lambert and Goldacre, and the BMA cohort surveys, amongst others. Dr Samantha Scallan, GP Education Manager, Wessex Deanery Dr Olga Zolle, Research Fellow in General Practice, Wessex Deanery [1] Todres M, Stephenson A, Jones R. Medical education research remains the poor relation British Medical Journal 2007; 335: 333-335 [2] Pitts J. Judging educational research and the selection of papers for publication Education for Primary Care 2004; 15(2): 143-149 [3] Carr W. For Education: towards critical educational enquiry. Buckingham: Open University Press, 1995 Competing interests: None declared |
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Mark J Newman, Associate Director EPPI-Centre, Social Science Research Unit , Institute of Education, University of London
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I would like to congratulate Mathew Todres and his colleagues1 on highlighting some very important issues in the field of medical education research and moreover in providing some empirical evidence to support their analysis. Unlike the authors of a number of the rapid responses to this piece I do not read into the paper any claims by the authors that all unfunded research lacks rigour or that the RCT is the method of choice in medical education research. I take my hat off to those correspondents (and to the countless other academics and practitioners) who do their research in their spare time and it is certainly the case that small scale studies can be rigorous and well executed. Nevertheless it is case that if we want to produce research evidence that can provide robust evidence to guide our responses to the many issues of practice that medical education has to address (such as those the authors outline) we need more larger scale studies using types of research design that are relevant to the research question posed (which will mean different questions and different research designs). This will require more funding. The funding situation is I believe common for education research across the healthcare professions and I agree with Robert McKinley 2 that it may be time for the various interest groupings in medical education to further their interdisciplinary collaboration in order to lobby for appropriate levels of funding to made available for healthcare education research from for example the DoH / NHS. I contest Julian Archer’s 3 claim that there is widespread agreement in the education community that the RCT is not a useful tool. Archer 3 and Wall & Houghton 4 cite a paper by Geoff Norman 5 in support of this claim and they could have cited many others. Whilst Norman raises many important issues about the difficulties in the conduct and interpretation of randomized experiments, many other researchers in the education community do not agree with his conclusion that the RCT is not a useful tool. It is equally possible to find many other authorities that argue the case why the RCT is very useful for education one of which is the US National Academy of Science Committee on Developments in the Science of Learning 6. As John Sandars 7 notes what is important is the rigour of the method for answering the question posed. Different research questions require different methods. One type of question that is important to medical education research is about the impact on students of what we as teachers do. It is essential that any research that aims to answer such a question gives us confidence that any impact measured can be attributed to the activity being investigated and not some other cause. Well conducted randomised experiments are a very efficient and effective method doing this 8. I would end with a plea to members of the medical education community (and others) who may read this article to please do so with an open engaging mind. Do not look for imagined slights to your favoured ontological or epistemological position or evidence of supposed paradigmatic dominance. Instead take this piece of work at face value for what it is a robust demonstration of the need for more funding of medical education research. 1. Mathew Todres, Anne Stephenson, and Roger Jones Medical education research remains the poor relation BMJ 2007; 335: 333-335 2. Something needs to be done Robert K McKinley (23 August 2007) 3. Reply to Todres, Stephenson and Jones David W Wall, Guy Houghton (21 August 2007) 4. There is reason for optimism Julian Archer (22 August 2007) 5. Norman, G. Results confounded and trivial: the perils of grand educational experiments. Med Educ. 2003; 37(7): 582–584 6. Committee on Developments in the Science of Learning. How people learn: Brain, mind, experience and school (expanded edition). Washington, D.C.: National Academy Press. 2000 7. Only half a story! John E Sandars (21 August 2007) 8. Newman M. Fitness for Purpose Evaluation in Problem Based Learning Should Consider the Requirements for Establishing Descriptive Causation Advances in Health Sciences Education (2006) 11:391–402 Competing interests: None declared |
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Lynn V Knight, Senior Lecturer in Medical Education School of Medicine, Cardiff University, Wales, UK, Kieran Sweeney
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The particular perspective we have on the world fundamentally influences the underlying research design we deem appropriate. Moreover, the way this is manifested in the research process, is intimately connected to the underlying (implicit or explicit) perspective of the researcher. This will also affect how the evidence derived from the research is represented. Knowledge is not asocial. 'Data' is not just out there to be obtained by mechanical, neutral process. Rather data are constructed according to the framing of the research topic and the theoretical assumptions that researchers have of the world. Of course, the same is true of clinical practice in medicine, where the explanatory model indicates our predilection for certain types of knowledge (RCTs), which, in turn, betrays the underlying, tacit and rarely debated, positivist ontology of medicine's practitioners. Thus, while the plea for more theoretical rigor in medical education research made by Todres et al [1] is a plea that few can deny, their own underlying assumptions of what medical education research is, and how theoretical rigor can be achieved, revealed the essence of the problem: The plea itself lacked the very rigor the authors called for. Firstly, the authors failed to explain what their concept of 'medical education research' is. Without a clear definition of the concept, their analysis of the situation lacks both reliability and validity. Indeed, the concept of medical education research, along with the issue of whether it can be conceived of as a 'field' (p334) in its own right, is not unproblematic. How it relates to nurse education, other vocational educational contexts, to the broader concept of professional identity formation and to disciplines such as psychology and sociology need to be explored. This fundamental oversight therefore influenced the statistics cited throughout the paper. For example, in their "recent medical education research" section, the authors restricted their analysis to primary and secondary research articles from only four journals, two of which are not specialist in the field of education. Serious researchers in medical education contexts do not confine their output to journals with constraining word limits which restrict rigorous analyses and debate, but will seek out those contexts that enable them to deliver higher quality work in journals such as Qualitative Health Research [e.g. 2] Social Science and Medicine [e.g. 3,4] and Advances in Health Sciences Education [e.g. 5]. The analysis presented therefore failed to consider studies published more widely in other journals outside these restrictive contexts and revealed the authors lack of interest in theoretical debate. Furthermore, the authors did not explicitly outline (and defend) what comprises "methodological rigour." If, however, the authors believe that methodological rigor equates to more randomized control trial, experimental designs, case control studies and meta analyses, then we believe that medical education research is all the better for it. In our opinion bringing rigour into medical education requires fundamental changes in current practice. For example, researchers could begin by making their own theoretical perspectives explicit. This critical first step in the research process will enable researchers to consider the role of theory in their work and thus adopt the most appropriate methods for the individual research questions they wish to address. Moreover, from these considerations, researchers can begin to bridge the theory-practice divide by aiming to inform practice whilst developing theoretical understanding. This might be best undertaken through interprofessional team working collaborations. For example, we have found that by working together as an MD-PhD collaboration we have been able to explicate theoretical and practical issues within our own work. Furthermore, by situating our work in the broader theoretical perspectives we are able to apply for research funding outside the narrow confines of medical education. Indeed, we are about to embark on a two-year international study (three geographically distributed medical schools across the UK and Australia) investigating medical students' explanations of behaviour following professional dilemma situations, funded by a large grant from the British Academy. Other research undertaken by us has been funded by bodies such as the Nuffield Foundation and Support for Science. If researchers in medical education are to become more theoretically and methodologically rigorous then we need the context within which to do so. Protected time for researchers is essential along with the freedom to publish works that are more discursive and analytical in character. The journal Advances in Health Sciences Education is unique in this area giving authors no word restrictions for their articles, but judging each one on merit. But here lies the rub, in order to further drive quality in research, skilled and dedicated peer reviewers are an essential, but scarce, element. However, we fear that the elements are against us, as the current research assessment exercise in medicine favours laboratory based experimental work, above all other kinds of enquiry: theoretical debate is left out in the cold, the domain of the boffin. [1]Todres M, Stephenson A, Jones R Medical education research remains the poor relation British Medical Journal 2007; 335: 333-335 [2] Wilkinson CE, Rees CE, Knight LV. “From the heart of my bottom”: Negotiating humour in focus group discussions. Qualitative Health Research 2007; 17;411-422 [3] Lingard, L., Garwood, K., Schryer, C. F., & Spafford, M. M. A certain art of uncertainty: case presentation and the development of professional identity. Social Science & Medicine 2003; 56, 603-616. [4] Knight, L. V. & Mattick, K. `When I first came here, I thought medicine was black and white': Making sense of medical students' ways of knowing. Social Science & Medicine 2006; 63, 1084-1096. [5] Knight LV, Rees CE. “Enough is enough, I don’t want any audience”: Exploring medical students' explanations of consent related behaviours. Advances in Health Sciences Education, in press; DOI 10.1007/s10459-006-9051-1 Lynn Knight knightlv@cardiff.ac.uk Kieran Sweeney kieran.sweeney@pms.ac.uk Competing interests: None declared |
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Stewart Lloyd, Consultant Occupational Physician Perth, WA 6000
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I have only just read the article, because of the postal delay in getting it to me in WA. How disappointing to see an article on medical education illustrated by a photograph of a young lady, obviously being educated in otoscopy, using a completely inappropriate method of holding the otoscope. Competing interests: None declared |
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Mathew Todres, Research Associate Department of General Practice and Primary Care, King's College London, SE11 6SP, Anne Stephenson, Roger Jones
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Authors’ reply We are pleased that our Analysis article on medical education research1 has stimulated debate, and particularly appreciate Mark Newman’s even-handed appraisal2 of the various points of view that emerged. We used a limited literature review to show that medical education research has a low profile in major general medical journals, is frequently unfunded and is often difficult to generalise beyond its institutional setting. We did not imply that the predominantly quantitative studies which we discussed represent the only useful research approaches, and we think that our conclusions are equally applicable to the qualitative and theoretical literature on medical education. Most of all we wanted to make the case that research into medical education generally, and the medical undergraduate curriculum in particular, deserves much better funding and support. 1. Todres M, Stephenson A, Jones R. Medical education research remains the poor relation. Brit Med J 2007; 335; 333-5 2. Newman M. Health care education research: funding and RCTs are both needed. Brit Med J 2007; 31 August Competing interests: None declared |
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