Time for evidence based medical education

No doctor will deny the need for evidence based clinical practice, and all responsible professionals try to keep up with research in their discipline.¹ For many, however, the education of the next generation of doctors is also a major responsibility, yet the same professional standards are not so commonly applied. All doctors have been successful medical students, and it seems easy to assume that this alone qualifies them to educate others. Few surgeons would claim that surviving a surgical procedure qualifies a patient to perform it on another, yet how often do we hear, “There was none of this gobbledegook in my day, yet I learnt medicine well. I know about medical education. I’m not going to change.” Why do these attitudes persist? What are the barriers to effective, evidence based medical education, and how may they be overcome?

It is hard for clinical teachers to learn about medical education research, partly because there is not that much of it. Grants for research in medical education are difficult to obtain. In the United Kingdom a new doctor costs twice as much as a Rolls Royce car, and at least £1bn ($1600bn) a year is spent on medical education,² yet the funds available for research and development of medical education are tiny, amounting in total to little more than a couple of decent grants in molecular biology. For example, funding to UK medical schools specifically to support curriculum change following publication of Tomorrow’s Doctors by the education committee of the General Medical Council³ was less than £50 000 per school over each of four years. Welcome though this support was, it offered little scope for research at a time when opportunities for good work were outstanding.

Despite these privations, some very good work is done, but many clinical teachers still don’t seem to know about it. Major journals publish little on the subject. The BMJ is better than most, but there is still only a handful of papers each year. An electronic search using the keywords “education” or “medical education” over most high profile, general journals yields little other than book reviews. There are, of course, specialist medical education journals,⁴ but these seem to be regarded by most doctors as somebody else’s business. There are good reviews and guides to be found once clinical teachers begin to look—all we need to do is persuade them.

Many clinical teachers think they will not understand educational research anyway. Educational theory has not figured in medical training until very recently, and educational research has its own jargon. Some debates in medical education can appear to the outsider to have an almost religious fervour to them, which may be off putting. It is as important to have precise definitions in medical education as in any other discipline, but long debates about just what is meant by problem based learning⁵,⁶ or the difference between community oriented and community based can easily alienate the uninitiated. Educationalists do not always help their cause by the ways in which ideas are communicated.

Even if clinical teachers think they understand what the research is about, they can be suspicious of it. Educational research does not often use randomised controlled trials.⁷ Much research is qualitative, and outcomes of educational processes are often difficult to evaluate and not detectable until years after the event. Studies can be perceived to be poorly designed, conducted, and analysed and the results dismissed as not generalisable. This is despite, for example, an extensive, scientifically valid literature on methods of assessment.⁸ Although this perception is perhaps no more true of educational research than some other types, the ignorance of most practitioners allows the scepticism to survive. The task of convincing the average doctor in the consulting room is not, therefore, an easy one. If medical education research is to inform more teachers it must become accessible, comprehensible, convincing, and demonstrably related to the real issues faced by medical teachers at the bedside or clinic.

An important starting point is for a major journal to pick up the torch and publish for a general readership educational research that meets strict guidelines for quality. In the longer term we need to produce new doctors who understand the educational process and who can interpret the research they read. Many new medical curriculums strive to help students understand the learning process itself,⁹ and in time these students and new graduates will spread the word. In the meantime it is up to medical educationalists to present ideas in clear, jargon free format; to show that research methods are designed for the task and competently carried out; and to convince their colleagues that the evidence base is as important in educating new doctors as it is in assessing a new chemotherapy.

Education and debate pp 1265-83