Letters to the Editor
To the Editor: I applaud Cook and West1 for their timely essay highlighting the pitfalls of solely focusing on patient-centered outcomes in medical education. Below, I wish to contribute to the ongoing conversation about the direction of outcomes research in medical education.
In his thought-provoking commentary published in 1995, Evans2 cautioned about the danger of evidence-based medicine in the elderly degenerating into evidence-biased medicine. There is an uncanny similarity between the issues confronting geriatric medicine then and those raised by Cook and West: the “black-box” of multiple complex interventions that results in dilution and failure to establish a definitive causal link, the problem of shifting baseline such that the effectiveness of an intervention may be more indicative of how bad the prevalent standards are rather than how useful the intervention is, and the selection of potentially biased outcomes founded upon expediency. There is a pressing need to reconsider the focus of outcomes-based research to guard against a slide into outcomes-biased research, akin to the proverbial salesman who single-mindedly peddles his wares instead of offering solutions based on the customer’s needs.
I advocate that the field should not throw out the baby with the bath water but, instead, adopt outcomes-balanced research, which begins with a focus on the research question rather than on the outcome.1 As opposed to strict adherence to a rigid hierarchy, the best outcome would be the outcome that best answers the research question within a given context; this may sometimes involve “lower-level” learner-centered outcomes or nonoutcomes research designs, such as those used in qualitative studies. The field also needs to pick up the gauntlet of developing innovative outcome measurements that are credible, acceptable, and educationally sensitive. Examples include the use of social networks to study complex doctor–nurse interactions in acute health care settings,3 patient-reported outcomes measured via well-designed surveys,4 and program evaluation frameworks, such as the outcomes logic model, which link assumptions and planned activities with intended outcomes.5
Wee-Shiong Lim, MBBS, MRCP (UK)
Senior consultant, Department of Geriatric
Medicine, Tan Tock Seng Hospital, and faculty
advisor, Health Outcomes and Medical Education
Research, National Healthcare Group, Singapore;
1. Cook DA, West CP. Perspective: Reconsidering the focus on “outcomes research” in medical education: A cautionary note. Acad Med. 2013;88:162–167
2. Evans JG. Evidence-based and evidence-biased medicine. Age Ageing. 1995;24:461–463
3. Lim I, Chia CK. Making birds of different feathers flock together: Common skies for interprofessionalism. August 25–29 2012 Lyon, France Paper presented at: Annual Meeting of the Association for Medical Education in Europe
4. Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med. 2013;368:201–203
5. Armstrong EG, Barsion SJ. Using an outcomes-logic-model approach to evaluate a faculty development program for medical educators. Acad Med. 2006;81:483–488