Medical education comes of age.

Abstract

It is a capital mistake to theorize before you have all the evidence. It biases the judgement. Conan Doyle in A Study in Scarlet, 1888 A short piece in John Mortimer’s Clinging to the Wreckage illustrates the power of evidence – even when it is short supply: Often he would tell me of his triumphs and I must have been very young when he said, ‘Remarkable win today, old boy. Only evidence of adultery we had was a pair of footprints upside down on the dashboard of an Austin Seven parked in Hampstead Garden Suburb.’ Evidence-based medicine is an important concept. It means critically reviewing current practice against published evidence using a hierarchy of study designs as the yardstick for drawing conclusions. The randomized-controlled trial (RCT) is the gold standard. If using the best available evidence is important for clinical practice, what should be our approach to medical education? Should what, and how, we teach be based on the best evidence about effectiveness and relevance for learning? Of course it should – but what is the evidence that guides us in our day-to-day practice as teachers? The term ‘best evidence medical education’ (BEME) has recently been introduced to address this issue.1 BEME is the implementation of educational methods and approaches that are based on the best available evidence of their effectiveness. Speakers at a recent conference held in Sweden, organized by the Association for Medical Education in Europe (AMEE), addressed these questions from a variety of perspectives. Cees van der Vleuten from Maastricht reviewed evidence about learning methods from the perspective of the cognitive psychologist. He emphasized the importance of the learning context – of encouraging students to use what they already know and of making links between existing knowledge and new information. Knut Aspregen reviewed studies describing evidence surrounding the most effective ways of teaching communications skills and Philip Davies described a review of the evidence for using a variety of approaches to teaching, including problem-based learning. He also announced the establishment of an international network of researchers similar to the Cochrane Collaboration, to initiate and coordinate systematic reviews of research into social and educational interventions. The conference presentations raised a wide range of questions. These included concerns about the prominence of quantitative approaches to research at the expense of qualitative studies, with fears expressed that this trend supported the view that knowledge acquisition, rather than understanding, was the main purpose of learning. Furthermore, for many educational research studies, the RCT may not be the most appropriate gold standard. Equally rigorous methodology appropriate to the investigation must be considered. The AMEE conference not only demonstrated that more than footprint evidence exists about the effectiveness of medical teaching, but also exposed the problem that there is widespread ignorance of this evidence. Whilst conferences and journals can have a major role to play in disseminating research results (this journal has recently published the results of a number of controlled trials234), more work is sorely needed to determine how change at the chalk face can be influenced by evidence.5 Another strong message to emerge from the conference stressed that the quality of research, as well as quantity, is an issue. We all want medical education to progress effectively and we want evidence collected by the best possible research.6 There are concerns however, that the evidence-based approach, with its strong emphasis on the RCT, may influence many of the questions that are asked and dictate the research methods used, to the exclusion of others. At the beginning of his presentation Cees van der Vleuten said that the AMEE conference had now ‘come of age’– an observation that reflected the large international audience, drawn mainly from Europe and North America. But perhaps it is medical education that has come of age? Medical teachers are now more prepared to face up to difficult questions about what we should do and how we can do it. Seeking answers to these questions through the use of appropriate and rigorous study methods, and dissemination of results in an easily understood way is not an easy task, but it is one that we should undertake with energy, enthusiasm, and a sense of urgency.