Balancing academic medicine

Modern medical practice relies heavily on research evidence to guide us towards predictable, safe outcomes of investigations and procedures that aim to improve the quantity and quality of life. As there are still substantial gaps in knowledge, researchers are supported to add to the evidence base. New technologies are proven to be (or not to be) safer or more effective. This continual reflection on practice and drive to expand options and reduce error margins is lauded as scientific progress.

On the other hand, modern practice in medical education relies mostly on experience, opinion and rumour as it strives to produce graduates to meet the increasingly high standards of the community, partly in reaction to well publicised medical errors.1,2 Until recently, medical graduates received biomedical science training and apprenticeship-style clinical teaching without defined national exit standards. The current trend is towards broader (and possibly shallower) curricula guided by contemporary definitions of medical practitioner roles, such as CanMEDS from Canada, Good Medical Practice from the United Kingdom and local adaptations.3-5 National licensing examinations are either in place or under consideration, and international curriculum frameworks and accreditation are being developed.6 We are amidst an expansion in medical education driven by a workforce shortage.

However, do we know how to achieve this expansion and maintain quality? There is a relatively small evidence base to support changes in medical education practice. The science of medical education has evolved much more slowly than the science of biomedicine. Lectures have been around for centuries, human dissection for about 500 years, and laboratory sessions for over 100 years. The only two real jolts to the conventions of medical education during the 20th century were the Flexner report, which standardised pre-clinical and clinical training phases because of concerns about a proliferation of small, lower quality medical schools in the United States,7 and problem-based learning, which was based on an attractive theory that case-based, integrated learning was more likely to be remembered when similar clinical presentations were encountered later. Neither change was based on strong evidence, and many years later there is still little education research evidence that any curriculum approach is better.8,9

A fundamental problem is that the academic basis of medical education receives little recognition amidst complex agendas. From a health care management perspective, the main role of the health care system is the provision within budget of quality clinical care, and it is difficult to direct funding towards academic development. From a university perspective, medical schools are sources of resources and prestige, but mostly through research achievement. As a result, medical schools are becoming “two-team” institutions. First, there are the researchers, who charge ahead, based on well planned and supported ventures, aiming to “score” grants and publications, win competitions and attract attention, usually based on advances in biomedical and clinical sciences. Then there are the teachers, who stay in the background and guide the students. This is the team that earns the core, stable funding of the school and is responsible for seeing that graduates meet the broader curriculum objectives, but it receives little attention except during medical school accreditation processes. The focus on research means that the real rewards of medical academic life generally go to members of the research team.

Consider these questions: Why do some basic scientists who participate in education research decline to list that on their curricula vitae? Why are there apparently clear measures of research success, but not of teaching success? How hard is it for exemplary teachers to gain senior promotion without research success? How many national honours go to people who teach rather than research? How many prizes are available to reward great teachers? Why are there “league tables” for medical schools according to research success, reputation and difficulty of entry (based on very high academic performance), rather than for teaching quality?

Just as clinical practice and research inform each other, so too do educational practice and research, and yet there are concerns about the variable quality and focus of recent research in medical education.10,11 There is a need to go beyond short term evaluation projects and to address current gaps in medical education research evidence, some of which are listed in Box 1. Most medical schools now have medical education units, but these are often seen as organisers of the teaching team, rather than contributors to a recognised academic agenda. These are missed opportunities, as medical schools manage large amounts of data about teaching and learning implementation, and could convert much of their teaching and learning activity to research without substantial cost. Medical education funding often underpins priority-driven research, and could more overtly support medical education research. The external funding environment could make medical education research more attractive to the research community. More medical academics could be trained in the methodology of education research, which differs from that of clinical and laboratory research, to increase research capacity. In summary, it is time for medical education research to enter mainstream research agendas and become a research priority for universities.

Unless we strengthen academic medical education, teaching and learning will continue on a relatively uninformed basis, and our aim to produce safer, more efficient doctors will be under threat. This strengthening requires high level intervention to promote a culture change in medical schools, facilitated by strategies such as those listed in Box 2. Even if all these strategies were implemented, the impact on support for biomedical research would be small, yet the potential reward would be high. We would know much more about what we are doing in medical education, and medical schools could gain academic credibility not just through traditional indicators of success, but for doing what they were founded to do — to teach medical students well. After all, medical schools depend increasingly on their students’ fees.