‘Nothing is but what is not’

The current ‘paradigm war’ in which some health care education researchers are currently engaged adds to the case for a greater call on underpinning theory, and for more theory building research.

Abstract

Education research has been criticised over the years for its lack of practical application. There has been an over-emphasis on theoretical research isolated from the problems faced by teachers, with results that are far removed from the classroom setting where the findings of research should be applied. This lack of coherence between the theoretical and the practical has led to concerns about the usefulness of educational research both for policy makers and for teachers. Arguments of this nature suggest a distancing between researcher and teacher that encompasses not just a failure to understand each other's needs, but also a failure to share a dialogue about each others' work. Similar arguments can be found in medical education research. For example, Colliver has written that ‘there is a serious lack of evidence for the effectiveness of medical education as a specialised body of knowledge about teaching and learning which has been shown to have pragmatic consequences in real-world applied settings’.1 Colliver's concerns focus not just on the paucity of the evidence, but also on the effects this vacuum has on policy making and on practice. He uses the term ‘housekeeping’ research to describe the limitations of much-published research because of its often ‘technical and in-house’ nature, a finding supported by work published in this journal.2,3 What sort of policy issues could benefit from stronger research evidence? Here are some examples of the many. In North America, questions about the length of training for the MD qualification are being asked, with especial concerns about whether 4 years (the current practice with graduate entry) is long enough. In the UK, changes in the undergraduate curriculum following the General Medical Council's (GMC) Tomorrow's Doctors initiatives and increasing interest in the concept of quality and standards in higher education raise questions about the need for a national qualifying examination for graduates of medical schools (currently all medical schools in the UK have their own degree level examinations loosely monitored for equivalence of standards by a system of external examiners and infrequent visits by the GMC). In Australia, considerable interest in the needs of rural communities is leading to substantial public investment in remote and rural health care facilities; how can medical school curriculums be designed to prepare doctors for practice in these areas? However, there are other concerns. If criticism of education research in general has been about its lack of practical application, the position in medical education research is more complicated. Norman had the need for more basic research in mind when he wrote: ‘Presently our experimental, curriculum level interventions are rarely grounded in substantive theories about learning; instead they often amount to market research testing the effectiveness of the current winner in the popularity poll…’.4 A proportion of published research gives the impression that it has been conducted by merely applying a limited range of research tools to find the answer to a question that has been generated in a theory-free environment. The current ‘paradigm war’ in which some health care education researchers are currently engaged adds to the case for a greater call on underpinning theory, and for more theory building research. Most recently, Whitcomb, as editor of Academic Medicine, has analysed manuscripts submitted to that journal and concludes that ‘too much of the research presently being conducted is focused on questions of only marginal significance, and the scope of the research being conducted is too narrow’.5 Here, Whitcomb is concerned not that current research is too theoretical in its focus, nor that its results do not help the clinical or basic science teacher, but that it does not sufficiently address the relationship between teaching and subsequent clinical practice. One significant consequence of this failure by the academic community to call itself to account for its educational programmes and for its teaching, he suggests, is that grant support for future research may begin to dry up as funding agencies seek a more health outcomes-orientated approach to their programmes. A major part of the solution, writes Whitcomb, is the need for medical education researchers to focus more on graduate programmes and their effects rather than, as at present, looking almost exclusively at undergraduate teaching. His agenda for such research includes identifying the types of educational interventions that improve clinical outcomes; finding out how well clinical training programmes match their graduates for high quality clinical practice and providing data to assure the public that doctors are well prepared to practise medicine. It is a tall order to ask for such a dramatic change in orientation of research activity towards goals that many would see more properly as crucial aspects of curriculum governance and lying more comfortably within the field of evaluation rather than research.6 It is also a change of direction that, if fully implemented, would seriously disrupt progress in our understanding of the structures and processes involved in successful education not just at undergraduate level but also, and possibly much more importantly for patient care, at the level of continuing professional development. We have previously defined medical education research as the ‘critical, systematic, study of teaching and learning in medicine including scholarly analysis of the context, processes and outcomes of all phases of medical education’.7 The results of this work will, amongst many other influences, affect the ways in which doctors and students learn to practice at the clinical interface with patients. What is needed is not wholesale conversion of effort from a large and diverse area of academic endeavour to a specific and particular target, but high quality research that can inform policy and practice, draw on and contribute to relevant educational theory, and make a significant contribution to improving patient care. This journal will be pleased to consider manuscripts addressing any or all of these areas within the undergraduate, postgraduate or continuing professional development fields.