J. Cleland and T.E. Roberts

Introduction

It has been said that in the past the practice of medicine was simple, safe and largely ineffective; today it is much more effective but complex, and potentially dangerous. More than ever, then, medical education needs to prepare and support students and doctors in their roles as providers of safe healthcare. Within the UK the amount of time spent as a trainee has changed dramatically within the last decade. Streamlining of medical training and the implementation of the European Working Time Directive has meant that education and training will need to be delivered differently, and knowledge and skills cannot be expected to osmose into trainees merely from them spending time within that discipline. Not only have major changes occurred during the trainee years but modern consultants and senior GPs are different too. There is recognition that mastery of a medical specialty is impossible and that the key to high-quality patient care is nested within continuous professional development and adopting an attitude of lifelong learning. All these changes have meant that medical education has achieved a new prominence and importance, and following the development of evidenced-based clinical practice it is becoming increasingly accepted that medical education should be evidence-based rather than founded on pragmatism, fashion and whim (Todres et al 2007).

Alongside this increasing acknowledgement of the importance of educating medical professionals has grown an interest in medical education research.

Until recently many individuals undertaking this research work have been interested amateurs, clinician-teachers who have not undertaken formal training in the area of educational research but who may have a track record of research in their own clinical area. Others have a background in the social sciences, bringing their own research conceptualizations of learning but having to apply them to a very specialized and hitherto tightly collegiate, disciplined club that they do not always understand in-depth and by whose members they have been viewed with suspicion. Tensions have also arisen between those who have sought to undertake research into medical education for its own sake, the so-called ‘research for researchers’, and those who feel that research should inform practice: ‘research for practice’.

In this chapter we propose that medical education research can be described as conducting and evaluating original enquiry and developing innovation, using appropriate theoretical and conceptual frameworks in order to achieve meaningful outcomes which advance the understanding and practice of medical education, and that this can be usefully thought of under the umbrella term of scholarship.

Medical education scholarship therefore should inform continued improvement of medical education locally and also seek to influence medical education policy and practice nationally and internationally. Thus, medical education scholarship is grounded in the real world of medical education practice and, in turn, medical education practice informs work undertaken under the heading of scholarship. This is analogous to applied research, where research yields actionable knowledge.

The Leeds Institute for Medical Education (LIME) has developed a useful representation of this idea of scholarship (Fig. 49.1) (Kilminster & Roberts 2010, personal communication). Other colleagues, such as those at the Karolinska Institute in Finland, have independently developed similar concepts. The LIME model consists of two circles of activity. The ‘internal’ circle relates to work generated and undertaken in the educators’ own institution for the benefit of its staff, students and trainees. The ‘external’ circle relates to activities undertaken outside the educators’ institution such as disseminating good practice developed as part of their ‘internal’ circle work or undertaken in response to external issues or challenges.

Next, we provide examples of how this model has or might be used to structure the scholarly work undertaken by medical educators.

The internal circle

Accurate assessment of competence is fundamental to any medical education programme. Some years ago at one of our institutions concern was expressed about the reliability of the final assessments (identification of issues). Members of the medical education unit (MEU) undertook an analysis of these issues and reviewed the literature and examined theories of assessment to identify best practice (academic activities). The result of these activities was the use of item response theory to analyse question performance, the production of a number of workshops to address areas such as question, OSCE station construction, examiner and simulated patient training (outputs). These workshops were piloted, evaluated and, where appropriate, adopted into mainstream practice (local impact) and formed a very obvious example of scholarship-informed local medical education practice. Continued evaluation and further identification of new issues feed the continuation of the internal circle. These activities also fed into external work (Fig. 49.2).

It has become increasingly obvious that teaching, learning and assessment of the development of medical professionalism are as important as the development of medical knowledge and skills. Many of the referrals to regulatory bodies are related to medical professionalism issues. Work by Papadakis and colleagues (2008) has shown that doctors who were reported to state licensing bodies in the United States had often had professionalism issues when in medical school when their records were examined (identification of issues).

Improving the curricula in this area involved a series of academic activities. An initial literature search was undertaken to identify a definition of professionalism together with characteristics identified with the term professionalism. A separate literature search was undertaken to investigate methods of assessment of professionalism. Within the institution a series of semi-structured interviews were undertaken with a range of healthcare professionals and undergraduate students to identify characteristics associated with the individuals who would be considered excellent role models for professionalism. Using the results of the literature reviews and empirical research, a curriculum and associated assessment programme was devised, piloted (evaluation), refined and subsequently adopted (outputs; Fig. 49.3).

In the UK there has been considerable criticism about the performance of medical graduates and their ability to function as doctors in the National Health Service (NHS). In national surveys new doctors have expressed the feelings that the education they received as part of their undergraduate studies did not ‘prepare’ them for the work they were expected to undertake. Employers, too, bemoaned the lack of ‘preparedness’ of new doctors (identification of the issues). In an effort to understand the issues and with recognition that these issues were seen in other groups of new workers and expressed by non-health-related employers, an extensive programme of research was undertaken, involving a series of academic activities. First, a literature search on the issues of transitions from education to the workplace not only in medical education but also in other areas such as engineering was carried out. Interviews were conducted with a range of different stakeholders, for example, newly qualified doctors, ward nurses, pharmacists, managers and senior doctors. Finally, a number of extensive periods of observations of new doctors in the workplace were conducted, covering a range of different times and places to look at actual learning practices. This study showed that ‘performance’ of newly qualified medical practitioners was related not only to personal attributes of the individual but also to the culture and support within the workplace and organization. It became obvious that learning about the local workplace culture was a very important aspect that influenced how well a new trainee was perceived as performing (outputs/analysis of characteristics). So, workplaces which specifically sought to induct new members into local practices produced environments where these incomers were more likely to feel able to perform well and to be seen as performing well. These times of transition were labelled ‘critically intense learning periods’ or CILPS. It was also clear that one-off inductions, usually consisting of a day of endless induction lectures to new organizations, were both inadequate and inappropriate.

The next stage of the research is to move the outputs into practice by developing work placement ‘change laboratories’ to help organizations recognize these CILPS and provide specific support for staff during this time and evaluating the acceptability and impact of this innovation.