commentaries Lost in translation: why medical education research must embrace ‘real-world’ complexities Sarah Yardley There is little purpose in conducting research, or any enquiry, unless it has functionality beyond the realms of academia. In this commentary, I argue that there is an ongoing need for medical education researchers to revisit this claim, considering its implications for our discipline. To ensure education remains fit for purpose, the medical education community should reject a false divide between research focused on learner impact and research focused on patient impact. The emergence of translational research in, for example, the form of improvement (also called implementation) science to connect medical sciences with real-world practices should also be heeded as a warning. Unless we want the evolution of medical education research to continue its historical emulation of research in the biomedical mould, thereby creating a similar need for translational research, we must work in genuinely cross-disciplinary ways that engage with theory and practice, both clinical and educational. Without this our research endeavours will fail to have utility or uptake in the ‘real world’ of work and learning in health care practices. To avoid this pitfall I suggest we reconsider
Keele, UK
Correspondence: Dr Sarah Yardley, Keele Medical School, Keele University, Keele ST5 5BG, UK. Tel: +44 1782 734679; E-mail: [email protected] doi: 10.1111/medu.12384
three themes crucial to high-quality, practically applicable education research. There is little purpose in conducting research, or any enquiry, unless it has functionality beyond the realms of academia
RECOGNISING THE CONTEMPORANEOUS NATURE OF WORKPLACE LEARNING AND HEALTH CARE DELIVERY
Education to future-proof the delivery of individualised needsbased health care should commence with greater attention to the contemporaneous nature of workplace-based learning and health care delivery. Both happen in the same place, at the same time and with the same people. Education and health care are social activities, dependent on relationships among people and institutions. We should reject the positioning of workplace activities as being either patient-centred or learner-centred because good patient care and good workplacebased learning are relationshipcentred, dependent on respectful collaboration and the negotiation of priorities and purpose. Appropriate patient care and the education of future professionals are not mutually exclusive. People learn spontaneously, whether they are in a ‘learning role’ or receiving health care, as a result of an intrinsic human need to make sense of life’s experiences. The learning of
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
professionals and patients today will affect the health care outcomes of the future. Recent reviews of poor health care highlight what happens when structural solutions are provided to problems dependent on human interactions.1–3 Dangers arise if people lose sight of the need to gain expertise through supported time for on-the-job learning of when and how to apply underpinning principles in health care. This is despite awareness that meeting educational needs can have direct positive impacts on patient care.3,4 The learning of professionals and patients today will affect the health care outcomes of the future
CONDUCTING EXPLANATORY EDUCATION RESEARCH CONTEMPORANEOUSLY TO PRACTICE
One of the strengths of education research lies in its power to explain complexities in the ‘real world’. Empirically informed education theory can help explain how and why complex social interventions may (not) produce targeted outcomes, particularly when used in combination with scholarship from the wider field of research in work and learning.5 Translation from research to practice should be at the heart of every education research activity, not a void to be filled, for better or worse, through serendipitous activities of educators. Researchers
225
commentaries must strive to keep to the fore awareness that educators have to live and work in the gap between academia and the realities of daily clinical practice. There is little point in teaching ideals and aspirations for good clinical practice unless learners see these replicated by experienced clinicians in the ‘real world’. Rather than taking the translational role of the doctor-as-educator for granted, researchers should pay greater attention to workplace dynamics, and work collaboratively and critically with educators, patients and learners to ensure maximum benefit and minimum harm in education and direct patient care.
needs both. Secondly, to pursue a linear model to its logical conclusion results in the devaluing of research which seeks to simultaneously develop fundamental understanding and provide realworld utility (Stokes labelled such scholarship as residing in ‘Pasteur’s quadrant’6). Medical education research can derive strength from operating in the messiness of Pasteur’s quadrant and resisting categorisation into the persistent biomedical research models that have created a need for translational research.
We should also be wary of defining only certain methods of scholarship as true ‘research’
Translation from research to practice should be at the heart of every education research activity
USING THEORY AND EMPIRICAL METHODS CONTEMPORANEOUSLY IN RESEARCH
We should also be wary of defining only certain methods of scholarship as true ‘research’. We must, of course, aim for the highest quality of (pragmatically achievable) research to inform and improve educational strategies and interventions. We should not, however, fail to acknowledge the lessons of the past, particularly with regard to spending undue time seeking to competitively contrast one methodology against another when in fact we need multiple research methods to address multifaceted questions. Almost 2 decades ago, Stokes6 argued that viewing research endeavours as a linear spectrum, from basic to applied, was unhelpful. Firstly, it encourages the polarisation of debate about which is of greatest value and should be given primacy when, in fact, society
226
THE WAY AHEAD? MEDICAL EDUCATION AS AN ACADEMIC DISCIPLINE SHOULD INTRINSICALLY BE AN IMPROVEMENT SCIENCE
We need to think more broadly about education in order to focus our endeavours on contemporary challenges in health care, such as the complexity of transitions for both patients and learners in clinical workplaces and the increasing complexities encountered in chronic illness and multi-morbidity. In any human endeavour the diversity of actions and interactions ensures the generation of unintended and unpredictable consequences.7,8 Strategies for managing (rather than avoiding) risk and learning through appropriately graded responsibilities represent two areas in which we might strive to operate within Pasteur’s quadrant in order to avoid disconnects between academics and practitioners, and learners and patients, and to usefully contribute to the development of safer and sustainable care.
Medical education research can derive strength from operating in the messiness of Pasteur’s quadrant
For all of these reasons, medical education research has much to contribute to and much to learn from a world in which it is increasingly recognised that health care continually functions on the edge of chaos.9 Perhaps the challenge is to reconceptualise medical education as intrinsically an improvement science for complex social interventions. I suggest that to do this, medical education researchers should further their efforts to address three intertwined objectives. These are: (i) to develop a rich understanding of the social processes and interactions leading to knowledge construction and meaning making in the real world of health care practices; (ii) to generate empirically and theoretically informed suggestions for change in collaboration with patients, learners and educators in the real world, and (iii) to conduct rigorous studies of interventions which include evaluation of the realities of implementation and subsequent consequences. Without these actions, medical education research will not address the gaps between ‘should work’ and ‘does work’ and will remain prone to offering solutions without really understanding the problems we are trying to solve. REFERENCES 1 Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive. London: Department of Health 2013. 2 Keogh B. Review in the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report. London: National Health Service in England 2013.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
commentaries 3 Neuberger J. Review of the Liverpool Care Pathway for Dying Patients. London: Department of Health 2013. 4 Anonymous. After Mid Staffs: the NHS must do more to care for the health of its staff. BMJ 2013;346: 1503. 5 Regehr G. It’s NOT rocket science: rethinking our metaphors for
research in health professions education. Med Educ 2010;44:31–9. 6 Stokes D. Pasteur’s Quadrant: Basic Science and Technological Innovation. Washington, DC: Brookings Institution Press 1997. 7 Reason J. Beyond the organisational accident: the need for ‘error wisdom’ on the frontline. Qual Saf Health Care 2004;13 (Suppl 2):28–33.
8 Merton RK. The unanticipated consequences of purposive social action. Am Sociol Rev 1936;1 (894): 904. 9 Stacey RD. Strategic Management and Organisational Dynamics: The Challenge of Complexity to Ways of Thinking about Organisations. Upper Saddle River, NJ: Pearson Education 2007.
The challenge of disruptive innovation in learning technology James Bateman & David Davies We know that computer-based instruction works.1 The question that remains to be resolved concerns what the most effective form of computer-based instruction might be. Are there consistent design attributes that will ensure the achievement of educational outcomes, and are there applications of learning theory that can be used to guide the design of effective computerbased instruction? The paper by Lau2 in this edition of the journal reviews a number of studies to derive a useful list of design principles to help guide the development of computerbased instruction modules. Readers may also wish to consult another list produced by Mayer and published in an earlier volume of this journal.3 The distinction between what constitutes computer-based teaching modules Warwick, UK
Correspondence: Dr James Bateman, Institute of Clinical Education, Warwick Medical School, Warwick University, Warwick CV4 7AL, UK. Tel: 00 44 247 574880; E-mail: [email protected] doi: 10.1111/medu.12410
(CBTMs), as defined by Lau,2 and other forms of computerbased instruction is not as clearcut. There is nothing inherent in multimedia learning, computerbased learning, Internet-based learning or related approaches that make them part of a blended learning approach, except that which the teacher has designed. Therefore, it could be argued that Lau’s2 CBTM is not a unique learning approach. However, we do welcome an evidencebased list of design principles, especially if it helps us to design more effective learning opportunities.
Are there consistent design attributes that will ensure the achievement of educational outcomes?
Lau2 describes the CBTM as a distinct approach, but this must be seen in the context of continued developments in web-based learning. New approaches in education, such as massive online open courses (MOOCs), have considerable overlap with the CBTM and
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
have the potential to demolish the rule book on how we approach educational interventions.4 MOOCs are wildly popular: course enrolments in the tens of thousands are common. They also benefit from considerable investment,5 yet they are so new that there is little or no evidence for how educationally useful they are, or how they might be financially sustained. This presents obvious challenges as to how we commission, develop, consume and evaluate online or computerbased learning. In particular, how can we create practical guidance for computer-based instruction when its technological underpinnings are constantly evolving? The technological world will not stand still long enough for us to understand its effects on our efforts to support learning. New approaches in education, such as MOOCs, have the potential to demolish the rule book on how we approach educational interventions
We know that where technical standards for e-learning technologies, such as virtual patients (VPs),
227
Keele, UK
Correspondence: Dr Sarah Yardley, Keele Medical School, Keele University, Keele ST5 5BG, UK. Tel: +44 1782 734679; E-mail: [email protected] doi: 10.1111/medu.12384
three themes crucial to high-quality, practically applicable education research. There is little purpose in conducting research, or any enquiry, unless it has functionality beyond the realms of academia
RECOGNISING THE CONTEMPORANEOUS NATURE OF WORKPLACE LEARNING AND HEALTH CARE DELIVERY
Education to future-proof the delivery of individualised needsbased health care should commence with greater attention to the contemporaneous nature of workplace-based learning and health care delivery. Both happen in the same place, at the same time and with the same people. Education and health care are social activities, dependent on relationships among people and institutions. We should reject the positioning of workplace activities as being either patient-centred or learner-centred because good patient care and good workplacebased learning are relationshipcentred, dependent on respectful collaboration and the negotiation of priorities and purpose. Appropriate patient care and the education of future professionals are not mutually exclusive. People learn spontaneously, whether they are in a ‘learning role’ or receiving health care, as a result of an intrinsic human need to make sense of life’s experiences. The learning of
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
professionals and patients today will affect the health care outcomes of the future. Recent reviews of poor health care highlight what happens when structural solutions are provided to problems dependent on human interactions.1–3 Dangers arise if people lose sight of the need to gain expertise through supported time for on-the-job learning of when and how to apply underpinning principles in health care. This is despite awareness that meeting educational needs can have direct positive impacts on patient care.3,4 The learning of professionals and patients today will affect the health care outcomes of the future
CONDUCTING EXPLANATORY EDUCATION RESEARCH CONTEMPORANEOUSLY TO PRACTICE
One of the strengths of education research lies in its power to explain complexities in the ‘real world’. Empirically informed education theory can help explain how and why complex social interventions may (not) produce targeted outcomes, particularly when used in combination with scholarship from the wider field of research in work and learning.5 Translation from research to practice should be at the heart of every education research activity, not a void to be filled, for better or worse, through serendipitous activities of educators. Researchers
225
commentaries must strive to keep to the fore awareness that educators have to live and work in the gap between academia and the realities of daily clinical practice. There is little point in teaching ideals and aspirations for good clinical practice unless learners see these replicated by experienced clinicians in the ‘real world’. Rather than taking the translational role of the doctor-as-educator for granted, researchers should pay greater attention to workplace dynamics, and work collaboratively and critically with educators, patients and learners to ensure maximum benefit and minimum harm in education and direct patient care.
needs both. Secondly, to pursue a linear model to its logical conclusion results in the devaluing of research which seeks to simultaneously develop fundamental understanding and provide realworld utility (Stokes labelled such scholarship as residing in ‘Pasteur’s quadrant’6). Medical education research can derive strength from operating in the messiness of Pasteur’s quadrant and resisting categorisation into the persistent biomedical research models that have created a need for translational research.
We should also be wary of defining only certain methods of scholarship as true ‘research’
Translation from research to practice should be at the heart of every education research activity
USING THEORY AND EMPIRICAL METHODS CONTEMPORANEOUSLY IN RESEARCH
We should also be wary of defining only certain methods of scholarship as true ‘research’. We must, of course, aim for the highest quality of (pragmatically achievable) research to inform and improve educational strategies and interventions. We should not, however, fail to acknowledge the lessons of the past, particularly with regard to spending undue time seeking to competitively contrast one methodology against another when in fact we need multiple research methods to address multifaceted questions. Almost 2 decades ago, Stokes6 argued that viewing research endeavours as a linear spectrum, from basic to applied, was unhelpful. Firstly, it encourages the polarisation of debate about which is of greatest value and should be given primacy when, in fact, society
226
THE WAY AHEAD? MEDICAL EDUCATION AS AN ACADEMIC DISCIPLINE SHOULD INTRINSICALLY BE AN IMPROVEMENT SCIENCE
We need to think more broadly about education in order to focus our endeavours on contemporary challenges in health care, such as the complexity of transitions for both patients and learners in clinical workplaces and the increasing complexities encountered in chronic illness and multi-morbidity. In any human endeavour the diversity of actions and interactions ensures the generation of unintended and unpredictable consequences.7,8 Strategies for managing (rather than avoiding) risk and learning through appropriately graded responsibilities represent two areas in which we might strive to operate within Pasteur’s quadrant in order to avoid disconnects between academics and practitioners, and learners and patients, and to usefully contribute to the development of safer and sustainable care.
Medical education research can derive strength from operating in the messiness of Pasteur’s quadrant
For all of these reasons, medical education research has much to contribute to and much to learn from a world in which it is increasingly recognised that health care continually functions on the edge of chaos.9 Perhaps the challenge is to reconceptualise medical education as intrinsically an improvement science for complex social interventions. I suggest that to do this, medical education researchers should further their efforts to address three intertwined objectives. These are: (i) to develop a rich understanding of the social processes and interactions leading to knowledge construction and meaning making in the real world of health care practices; (ii) to generate empirically and theoretically informed suggestions for change in collaboration with patients, learners and educators in the real world, and (iii) to conduct rigorous studies of interventions which include evaluation of the realities of implementation and subsequent consequences. Without these actions, medical education research will not address the gaps between ‘should work’ and ‘does work’ and will remain prone to offering solutions without really understanding the problems we are trying to solve. REFERENCES 1 Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive. London: Department of Health 2013. 2 Keogh B. Review in the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report. London: National Health Service in England 2013.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
commentaries 3 Neuberger J. Review of the Liverpool Care Pathway for Dying Patients. London: Department of Health 2013. 4 Anonymous. After Mid Staffs: the NHS must do more to care for the health of its staff. BMJ 2013;346: 1503. 5 Regehr G. It’s NOT rocket science: rethinking our metaphors for
research in health professions education. Med Educ 2010;44:31–9. 6 Stokes D. Pasteur’s Quadrant: Basic Science and Technological Innovation. Washington, DC: Brookings Institution Press 1997. 7 Reason J. Beyond the organisational accident: the need for ‘error wisdom’ on the frontline. Qual Saf Health Care 2004;13 (Suppl 2):28–33.
8 Merton RK. The unanticipated consequences of purposive social action. Am Sociol Rev 1936;1 (894): 904. 9 Stacey RD. Strategic Management and Organisational Dynamics: The Challenge of Complexity to Ways of Thinking about Organisations. Upper Saddle River, NJ: Pearson Education 2007.
The challenge of disruptive innovation in learning technology James Bateman & David Davies We know that computer-based instruction works.1 The question that remains to be resolved concerns what the most effective form of computer-based instruction might be. Are there consistent design attributes that will ensure the achievement of educational outcomes, and are there applications of learning theory that can be used to guide the design of effective computerbased instruction? The paper by Lau2 in this edition of the journal reviews a number of studies to derive a useful list of design principles to help guide the development of computerbased instruction modules. Readers may also wish to consult another list produced by Mayer and published in an earlier volume of this journal.3 The distinction between what constitutes computer-based teaching modules Warwick, UK
Correspondence: Dr James Bateman, Institute of Clinical Education, Warwick Medical School, Warwick University, Warwick CV4 7AL, UK. Tel: 00 44 247 574880; E-mail: [email protected] doi: 10.1111/medu.12410
(CBTMs), as defined by Lau,2 and other forms of computerbased instruction is not as clearcut. There is nothing inherent in multimedia learning, computerbased learning, Internet-based learning or related approaches that make them part of a blended learning approach, except that which the teacher has designed. Therefore, it could be argued that Lau’s2 CBTM is not a unique learning approach. However, we do welcome an evidencebased list of design principles, especially if it helps us to design more effective learning opportunities.
Are there consistent design attributes that will ensure the achievement of educational outcomes?
Lau2 describes the CBTM as a distinct approach, but this must be seen in the context of continued developments in web-based learning. New approaches in education, such as massive online open courses (MOOCs), have considerable overlap with the CBTM and
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
have the potential to demolish the rule book on how we approach educational interventions.4 MOOCs are wildly popular: course enrolments in the tens of thousands are common. They also benefit from considerable investment,5 yet they are so new that there is little or no evidence for how educationally useful they are, or how they might be financially sustained. This presents obvious challenges as to how we commission, develop, consume and evaluate online or computerbased learning. In particular, how can we create practical guidance for computer-based instruction when its technological underpinnings are constantly evolving? The technological world will not stand still long enough for us to understand its effects on our efforts to support learning. New approaches in education, such as MOOCs, have the potential to demolish the rule book on how we approach educational interventions
We know that where technical standards for e-learning technologies, such as virtual patients (VPs),
227
