Whitcomb, Michael E. MD
Each year at the AAMC's Research in Medical Education (RIME) Conference medical educators present to their peers the results of their own research studies, and participate in the analysis and discussion of research results presented by others. Since this year's RIME Conference—the 41st—was held just last week, it is timely to discuss in this editorial what I believe to be the greatest challenge now facing the medical education research community.
Since becoming editor of Academic Medicine, I have read every manuscript submitted to the journal. Having done this for the past year, and having reviewed the papers presented at this year's RIME Conference (published as a supplement to last month's issue of the journal) has been an education in the quality and scope of the research that medical educators have been conducting in recent years. It is clear that medical education researchers have been addressing many critical questions. Indeed, the results of a number of important studies have been submitted to the journal during the past year. But at the same time, 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. What is most lacking are studies exploring how the design and conduct of medical education programs affect the clinical outcomes produced by doctors.
To learn whether or not my overall impression of the state of medical education research might be in error, I decided to see what others have said about this over the years. Here is a sample of what I found:
Most research on professional education involves examining the effectiveness of the teaching and learning process without questioning whether either makes a significant difference in the health of individuals and groups.
RICHARD MAGRAW, DANIEL FOX, and JERRY WESTON (1978)1
There is a continuing uneasiness among thoughtful critics… that the research presented does not build on that which has preceded it. Few clear paths of research are being followed which could provide generalizable new knowledge to the field of medical education and have an impact on that field. Studies presented, to a large degree, focus on small details of the educational process and short-term evaluation rather than long-term outcomes for the broader field.
M. BROWNELL ANDERSON (1986)2
It is clear from the foregoing considerations that we have not been careful enough in our studies of the connection between performances before and after graduation from medical school. We have not been sufficiently scrupulous with our operational definitions of predictor and criterion variables. Consequently, we have not identified the best instruments for collecting the data or the best methods for analyzing them. In short, [there has been] a failure to identify the problem properly.
JOSEPH S. GONNELLA, MOHAMMADREZA HOJAT, JAMES B. ERDMANN, and J. JON VELOSKI (1993)3
There is a lack of theory-based research in undergraduate medical education. A large percentage of the published literature can be characterized as studies to evaluate the effect of a particular teaching method on one school using a convenience sample of medical students from that school. There is very little overarching theories of education that direct and inform the individual studies.
ALEXANDRA DIMITROFF and WAYNE K. DAVIS (1996)4
I will close with a challenge that applies uniquely to us as medical education researchers. Specifically, we are guilty of providing too many unrelated, almost uninterpretable, descriptive studies of small individual experiments.
CHRISTINE H. MCGUIRE (1996)5
Educators and administrators looking to this body of literature for information to optimize their educational decision making will be disappointed.
JAY PRYSTOWSKY and GEORGES BORDAGE (2001)6
So what is to be made of this? For starters, it is clear that leading members of the medical education community have recognized for some time that too much of the medical education research being conducted has not been designed to address the most important research questions. Of particular significance, they have noted also that researchers have not focused their attention on questions that relate to the connections between what is being taught and what practicing physicians actually do.
Concern about the linkages between medical education and health care outcomes is not new. Indeed, almost 25 years ago, the Work Group on the Education of the Health Professions and the Nation's Health, which was established by the director of the National Center for Health Services Research in January 1976, published in the Journal of Medical Education a detailed medical education research agenda. That agenda called for the research community to undertake studies designed to explore the relationships between specific medical education interventions and the clinical outcomes produced by practicing physicians. In the years that followed, Christine McGuire and other leaders of the medical education community reiterated the importance of conducting studies designed to link medical education to health outcomes. And yet, almost no research results have been published to meet that need.
The medical education research community must respond now to this important issue. During the past year, the Commonwealth Fund Task Force on Academic Health Centers challenged the academic community to take more responsibility for ensuring that medical education programs are producing doctors who are well prepared to provide high-quality care to the patients that seek their care. And more recently, the federal Agency for Healthcare Research and Quality has indicated the importance of undertaking research to fill this need. Unless medical education researchers more urgently focus their efforts on this challenge, I am concerned that the future of medical education research will be rather dim. If research results that are relevant and applicable to this issue are not forthcoming, I suspect that institutional support for medical education research will sharply diminish, and external funding, even the meager amount that is currently available, will become a thing of the past.
It will not be easy for the medical education community to meet this challenge successfully. To begin, it will require researchers to shift the focus of their attention away from the education of medical students—the subject of the great majority of medical education research studies—to the education of resident physicians. They will have to undertake studies designed to determine how well graduate medical education programs are preparing their residents to deliver high-quality medical care, and seek to identify the kinds of educational interventions that will improve the clinical outcomes produced by graduates of those programs. And to carry out this agenda, they will have to seek the cooperation of researchers from other disciplines, whom they have not collaborated with in the past, particularly those in the health services research community who are experienced in conducting outcomes research. Together these researchers will have to overcome the formidable methodologic challenges inherent in conducting such investigations.
Despite the magnitude of the tasks facing the medical education community, there is no choice except to accept them and move forward. More than ever, the public expects the academic community to ensure that doctors who are completing residency training and entering practice are well prepared to provide high-quality medical care. Medical education researchers have a responsibility to provide the data that are required for this purpose. It is time for the research community to embrace a research agenda that will meet this need. It is staggering to imagine what the present state of medical education would be like if the research agenda proposed by the Work Group on the Education of the Health Professions and the Nation's Health had been adopted by the research community 25 years ago. Even more important, imagine how the quality of health care might be improved in the future if the medical education community focuses its efforts on this agenda beginning today.
Academic Medicine is committed to supporting this effort by providing a forum for an ongoing dialogue on the most effective ways for undertaking this agenda. Also, while the journal will continue to publish high-quality research reports on all topics of importance to medical education, I plan to give particular attention to those that meaningfully address the link between medical education and practice, from either a conceptual or a research perspective. I hope this message will encourage medical education researchers, the leaders of academic medicine's institutions, and other journals to more deeply focus their attention on this critical challenge. All of us in the academic medicine community, regardless of the roles we currently play, have a responsibility to do what we can to improve the quality of the health care provided to the American public.
1. Magraw RM, Fox DM, Weston JL. Health professions education and public policy: a research agenda. J Med Educ. 1978;53:539–46.
2. Anderson MB. Silver Anniversary: AAMC Research in Medical Education Conference 1962–1986. Washington, DC: Association of American Medical Colleges, 1986.
3. Gonella JS, Hojat M, Erdmann JB, Veloski JJ. A case of mistaken identity: signal and noise in connecting performance assessments before and after graduation from medical school. In: Gonella JS, Hojat M, Erdmann JB, Veloski JJ (eds). Assessment Measures in Medical School, Residency, and Practice: The Connections. Acad Med. 1993;68(2 suppl):S9–S16.
4. Dimitroff A, Davis WK. Content analysis of research in undergraduate medical education. Acad Med. 1996;71:60–7.
5. McGuire CH. Contributions and challenges of medical education research. In: Research in Medical Education. Proceedings of the Thirty-fifth Annual Conference. Acad Med. 71(10 suppl):S121–S126.
6. Prystowsky JB, Bordage G. An outcomes research perspective on medical education: the predominance of trainee assessment and satisfaction. Med Educ. 2001;35:331–6.