The need for a firm evidence base for clinical practice is undisputed. Evidence of effectiveness, and of ineffectiveness or harm, necessarily informs decisions about patient care. The hierarchy of evidence is dominated by systematic reviews, meta-analyses and randomised controlled trials. Ideally, perhaps, such a rigorous approach should be brought to bear on innovations in the delivery of healthcare – the skill mix of the extended primary-care team, the balance between face-to-face and remote electronic consultations, the funding formulae to address problems of illness, deprivation, and inequality, for example. However, geographical and demographic heterogeneity frequently mean that the best solutions to delivery of care problems must be found locally, and sometimes urgently, rather than awaiting the results of large controlled trials, which may not be capable of providing generalisable results and frequently take so long to conduct that the answers are out of date by the time they have reported. Careful evaluation of local initiatives and new mechanisms to share and spread best practice may be more appropriate – the “middle ground“ research described by Guthrie and colleagues [Citation1].
In their leading article in this journal issue Schuwirth and van der Vleuten rightly underline the importance of a rigorous approach to research in medical education, and emphasise the need to choose appropriate theoretical and methodological approaches at a time of changing paradigms and an increasing focus on the individual learner, teacher and patient within the system. It might be worth adding to their analysis of medical education research some potential parallels with clinical and health services research, which in turn could help to re-focus medical education research in primary care at a particularly critical time for the profession and the health service.
Responding to Schuwirth and van der Vleuten’s challenge about research contributing to producing better doctors, it isn’t difficult to think of a substantial research agenda for primary care in the areas of, for example, clinical epidemiology, diagnostic decision-making, clinical skills teaching and learning, the management of multi-morbidity and psychiatric co-morbidity, student selection, and assessment and examination. The primary care evidence base for teaching and assessing these topics still requires work, and most are suitable for collaborative, large-scale quantitative studies, including trials, as well as qualitative work to add understanding and facilitate change and the implementation of new approaches. Longer-term research to examine, for example, issues such as early predictors of academic progression and career trajectory, and student characteristics and their association with professional development, would be greatly facilitated by creating databases of routinely collected institutional data, supplemented by additional voluntary surveys, stored for research purposes in medical schools – a medical education research equivalent of the Clinical Practice Research Datalink [Citation2], and a method which has been used successfully, for example, at the University of Cambridge [Citation3].
Multi-institutional research employing rigorous experimental or quasi-experimental methodology to study important questions likely to be generalisable across institutions stands the best chance of attracting scarce funding for medical education research. Medical education staffing in the face of rising student numbers, and uncertain institutional commitment to career progression based on teaching attainments are continuing difficulties: high-quality collaborative research may go some way towards addressing these obstacles.
In terms of sharing and embedding best practice, and learning from excellence in educational methods nationally and internationally, it might be worth considering a dissemination method outside the formal peer-reviewed literature, which can be a barrier to getting the results of evaluations of local initiatives into circulation. Some years ago, recognising that excellent innovations in practice relating to clinical care, practice organisation and professional roles, for example, were unlikely to meet the criteria for academic research papers, the British Journal of General Practice, along with the Clinical Innovation and Research Centre at the Royal College of General Practitioners launched Bright Ideas – a website portal aimed at hosting and promoting excellent examples of good practice, which has proved a considerable success. This is a possible model for medical educators, to share their evaluations of schemes which are necessarily local, devised to embed practice based on best evidence in a local context.
Some outstanding challenges for medical education research – what really does make a good doctor? – are elegantly described by Schuwirth and van der Vleuten. These include assessing a learner’s ability to function well in the increasingly complex and inter-professional environment of medical practice, assessing their propensity for self-directed, lifelong learning, measuring their sensitivity to socio-cultural factors in diagnosis and management, their ability to cope effectively with complexity and uncertainty, and their understandings of the processes and limitations of clinical reasoning. These are important topics to have in mind, with significant implications for the choice of research designs, many of which are likely to require repeated measurements and long-term follow-up and in some cases, ascertainment of clinical outcomes. At a time of major change in medical practice and in the traditional role of the doctor, under-supply of clinicians, and rapid global demographic change, asking new questions about medical education has never been more important.
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References
- Guthrie B, Gillies J, Calderwood C, et al. Developing middle-ground research to support primary care transformation. Br J Gen Pract. 2017;67(664):498–499.
- Hamilton W. Using the CPRD for public health research. Br J Gen Pract. 2018;68(672):334.
- Quince TA, Parker RA, Wood DF, et al. Stability of empathy among undergraduate medical students: a longitudinal study at one UK medical school. BMC Med Educ. 2011;11:90.