This is the fourth of 4 related posts.
As noted in a previous post about a new Virtual Issue, ASME is hosting a daylong meeting on Researching Medical Education. The meeting is organized into six strands. The post below is from Rakesh Patel, a faculty member and medical education researcher based at University of Leicester in the United Kingdom.
You are encouraged to comment in response to this post, and to continue the conversation ‘live’ at the meeting if you plan to attend.
By Rakesh Patel
What’s the point of the term MFFD? What’s the point of medical education research?
“Medically fit for discharge (MFFD)” is a phrase used in the workplace but what does it actually mean? I was receiving handover from the junior members of the team and after mentioning the name of the patient the phrase MFFD was occupying the space for diagnosis. When I questioned what was actually wrong with the patient or requested some more information about why the patient came into the hospital in the first place I was struck by the dumbfounded expressions on the faces of the individuals in question. I could of course now get on my soap box and show my age by saying “when I was an house officer, I knew all my patients and their blood results” so why don’t the doctors of today know this information. Taking a step back, perhaps I could reflect more about the factors that may have contributed to my perception that there was actually a problem with the phrase MFFD in the first place given it seems commonplace in the discourse of healthcare teams. Alternatively I could consider my observation from multiple perspectives to make better sense of the role that social structures and systems play in leading to people using this phrase in relation to the patient rather than the person. Either way, this example raises some important considerations for those interested in medical education.
Firstly from my perspective as a medical educator, understanding how best to educate those in training is key to achieving what I would like to see from a new doctor and that is the skills and appreciation to ‘know’ patients are more than just a label. Secondly, from my perspective as a medical education researcher, the example highlights the importance of stepping back and considering a problem from the multiple perspectives so greater insight is gained into a given problem or opportunity. Medicine and healthcare professions education face many challenges today however the transdisciplinary expertise possessed by researchers in this area can add significant value to advancing practice but also aspects related to teaching and learning. Finally, from my perspective as a trainee or a future patient, the example serves a reminder that the answer is rarely gained without discussion and reflection on what others, particular those whom were serve, have to say. The six papers chosen to stimulate discussion among those interested in the discipline will be used to consider their contribution to advancing the discipline of medical education as whole or advancing the understanding of research of learning in practice as is the theme of the conference.
Professional identity seems to be “new kid on the block” in terms of attracting attention from medical education researchers interested in the area of professionalism. Over the past few years, individuals have tried to increase our understanding of professionalism in our discipline through advancing research and scholarship. (Helmich et al. 2012) provided some empirical data from medical students in their early years about their lived experience of interactions with patients and the potential contribution of these experiences on their professional identity development. At the same time, (Burford 2012) published a paper recommending that consideration be given to the role of group membership in developing social identity in the health education context. For the novice clinical teacher these papers would both be retrieved following a search on ‘professionalism’ but how should readers make sense of the papers and apply the insights back into practice? Similarly, for the novice researcher, how should they make sense of the different approaches and develop methodologies and methods for researching the priorities areas in this theme?
Most recently, (Cruess et al. 2014) suggested better understanding of identity formation in medicine and of socialization in the medical environment could lend greater clarity to the educational activities used to support medical practitioners of the future develop the qualities of the “good physician.” A good physician in my opinion would not just write ‘MFFD’ in a set of medical notes as part of their daily review without some consideration to what this phrase actually means in the context of providing care out of hours or for patient safety in its widest sense.
When undertaking research in medical education, making explicit the underpinning research paradigms and perspectives on matters such as ontology, epistemology and axiology is important. This information is fundamental for understanding the perceptions, beliefs, assumptions and the nature of reality and truth (or knowledge of that reality) held by the individual or team undertaking the research. Furthermore, such matters also influence decisions about key aspects of the research such as study design and conclusions. These individual values are often not apparent to readers so appraising whether the approaches chosen by researchers are appropriate for the nature of the phenomenon under study or whether sufficient attention is given by the researcher to his/her world view, cannot be made at first glance.
(Chitsabesan et al. 2006) used semi-structured interviews using repertory grids and critical incidents to elicit preferred characteristics and behaviours of clinical teachers. In choosing this method, the authors attempted to justify their selection by suggesting items on surveys are constrained by preconceived ideas, potentially limiting the responses. Furthermore, the authors also propose that focus groups limit the expression of individual’s views since patients influence one another. The authors provide limited, or at times no supporting evidence for these assertions and ironically do not reflect on how their own values and beliefs are likely to influence the approach to the research. This creates uncertainty in the mind of the reader about the credibility of the findings and one could argue the process of traditional peer-review.
Uncertainty in medical education research was a theme at AMEE 2014 and during one of the invited symposia focusing on research, Lorelei Lingard suggested uncertainty arises from researchers not asking themselves a series of questions stated below:
- What questions are you not going to ask?
- Who are not your participants?
- What is the area not of interest
- What are you not looking for?
- What story do you not tell?
Although the answers to these questions prior to publication, they are often debated face-to-face or online after publication afterwards, and a ‘blog’ provides an excellent platform upon which to engage in such a conversation.
The paper by (Chitsabesan et al. 2006) can also be used to discuss another anecdotal observation that is prevalent in most disciplines such as medical education and that is the issue of researchers ‘fitting a problem to a given study design’ rather than ‘fitting the study design to a given problem’. Methodology and methods are the hallmark of good research and where individuals have limited knowledge or skills in these aspects, they could and should turn to others for answers. Researchers in medical education could learn from counterparts in the social sciences, arts and humanities as well as business, engineering and physical sciences.
The Researching Medical Education conference is a showcase of talent from one of these disciplines as well as a magnet for researchers interested in medical education where these methods can be found. The impression one wants to avoid giving when writing a paper is the one that suggests as authors, a chosen method or study design was selected prior to any thought was given to a research question or the individual values and biases possessed by the research team.
Furthermore, justification for one research method over another is a fundamental part of academic training yet attracts little scrutiny from journal editors as part of the peer review process as in the case example above. For readers and new researchers alike, the tacit knowledge that goes into picking or justifying one method over another is really important for reducing uncertainty and increasing clarity. Access to source literature for readers is key to making the implicit more explicit and avoid the trap of performing ’sloppy science’ as suggested by Caes Van der Vleuten and colleagues at another AMEE 2014 research symposium.
One of the outputs from quality research activity is ideally a significant contribution to the existing body of knowledge or literature (The Lancet 2013). It follows that the responsibility of researchers should be to identify the gap in the literature and justify the rationale for performing research. Without a clear rationale, there risks the tendency for researchers to engage in inquiry just for the sake of it. Virtual patients are real-life clinical scenarios that enable learners to emulate the roles of health care providers to obtain a history, conduct a physical exam, and make diagnostic and therapeutic decisions (Cook, Erwin & Triola 2010) . However their role in the teaching and learning remains unclear. They are expensive and resource intensive (Saleh 2010) therefore priorities for research in this area should be set by stakeholders such as learners or patients, rather than faculty or industry. A critical literature review of VPs conducted by (Cook, Triola 2009) identified design variations for VPs were limitless but called for further research to explore design issues. Nevertheless a systematic review of computerised VPs in health professions education performed by (Cook, Erwin & Triola 2010) suggested that VPs, irrespective of instructional design led to large positive effects interms of gains in learning.
Against this backdrop,(Bateman et al. 2013) chose to explore which form of virtual patient (VP) design may be effective and why among undergraduate medical students using a ground theory approach. Now from the learner perspective, this work may have lower priority in comparison to questions of greater relevance to them such as ‘will VPs make medical students better or safer doctors?’. For patients and the public taxpayer, the question they want answered is ‘what is the added value of VPs compared to other training modalities (such as real patient contact)? Likewise, clinical teachers and medical educators first want answers to questions such ‘what is the effectiveness of VPs for increasing the transferability of diagnostic decision-making skills into the workplace?’ before others more granular or specialist interest questions like activity design.
(Bateman et al. 2013) suggest educational theory plays little or no role for informing how best to design VPs yet there was an entire symposium at AMEE 2014 devoted to the use of educational theory for developing new technology-enhanced learning approaches based on insights from cognitive load (Sweller J, van Merrienboer J, Paas F 1998) and multimedia learning (Mayer 2001) theories, the former of which was rubbished by the authors above in the context of VPs. These assumptions were made without sufficient reference to the published literature so risks leaving the novice clinical teacher or even experienced medical educator unclear how best to make sense of the research, especially in regards to the justification for performing the research and the choice of methodology used to explore the problem.
Extending the notion that research which really matters should be taken conducted and progressed, (Darbyshire, Baker 2013) presents the experience of medical trainees as early career researchers in medical education. Without developing capacity in a new generation of medical trainees, the make up of researchers in medical education in the future may be similar to the situation facing health sciences now, where the dwindling numbers of medical academics is resulting in the reduced contribution from medical doctors within the discipline. Whilst it is encouraging to see medical education grow in terms of diversity, (Darbyshire, Baker 2013) remind us of the importance of ensuring part of the core contains medical doctors but with understanding about research methods and appreciation for the social sciences. Traditionally, medical doctors have entered medical education towards the end of their career or with an ‘interest in teaching’, however advancing an academic discipline requires more than just individuals with this motivation. Medical doctors wanting to be academic medical educators should have some understanding about scholarship in teaching and learning as well as knowledge of the various educational philosophies and research methods.
(Darbyshire, Baker 2013) only present data from six participants yet the usefulness of the findings for informing the current practice of supervisors of this sample population and the policies for supporting these trainees is potentially significant. Anecdotal conversations with colleagues suggest the problem of career development for medical trainees with an interest in medical education is growing. There are limited opportunities to harness the experience of those who have had previous success so this type of ‘evidence’, regardless of the ’n’ number is potentially invaluable for readers interested in creating similar opportunities in their local context.
The paper by (Kuper et al. 2010) draws together all the key points made in this blog post into a paper that demonstrates how medical education can add value to the development of medical students, trainees, and health care professionals as well as the care of patients at the bedside. Morbidity and mortality rounds (MMRs) are opportunities for healthcare professionals to come together and discuss learning points from aspects of care, which demonstrate the healthcare team’s strengths and areas for improvement in the context of a significant incident. (Kuper et al. 2010) used ethnography to observe the interactions and behaviours of staff at MMRs, as well as conducted interviews with both staff doctors and residents and triangulated the resultant data.
The use of multiple methods can be undervalued by the novice researcher. Some of the papers referenced above describe single methods for exploring a complex phenomenon, whereas (Kuper et al. 2010) demonstrate the value of using triangulating findings and developing a better understanding of reality or knowledge about the ‘truth’. (Kuper et al. 2010) identified that novices value content knowledge, yet these forums are ideally placed to provide opportunities for much more deeper learning around the values, beliefs and attitudes of healthcare professionals in the workplace.
Readers who have experience of these rounds will have first-hand accounts about the desire of healthcare professionals to seek detail about significant incidents, perhaps overlooking the very behaviours, which led to problems or adverse incidents in the first place. These meetings are also a barometer of a department’s workplace culture since meetings in which the focus is on learning lessons for the future are more likely to be associated with organisations in which there is a strong ethic for learning. The challenge as highlighted by (Kuper et al. 2010) remains re-framing the perceptions of trainees about what is important when in the professional role of a doctor – the patient and their safety.
I started this piece with a reflection about the work MFFD and I feel that my reticence about the term persists in terms of the usefulness of the phrase and the understanding about its use in the discourse among healthcare professionals. The challenge for clinical teachers, medical educators and medical education researchers is to ensure that content knowledge is not valued above the development of professional identity and patient safety. We have a responsibility to public and patients alike that we are advancing the discipline in the right ways and we are researching about things that actually matter. Patient care is not about the destination of discharge, its about the journey for the patient and ourselves. Medical students, doctors in training and doctors, let’s think of another term that doesn’t sound as though we only see the patient and not the person.
Bateman, J., Allen, M., Samani, D., Kidd, J. & Davies, D. 2013, “Virtual patient design: exploring what works and why. A grounded theory study”, Medical education, vol. 47, no. 6, pp. 595-606.
Burford, B. 2012, “Group processes in medical education: learning from social identity theory”, Medical education, vol. 46, no. 2, pp. 143-152.
Chitsabesan, P., Corbett, S., Walker, L., Spencer, J. & Barton, J.R. 2006, “Describing clinical teachers’ characteristics and behaviours using critical incidents and repertory grids”, Medical education, vol. 40, no. 7, pp. 645-653.
Cook, D.A., Erwin, P.J. & Triola, M.M. 2010, “Computerized virtual patients in health professions education: a systematic review and meta-analysis”, Academic Medicine, vol. 85, no. 10, pp. 1589-1602.
Cook, D.A. & Triola, M.M. 2009, “Virtual patients: a critical literature review and proposed next steps”, Medical Education, vol. 43, pp. 303-311.
Cruess, R.L., Cruess, S.R., Boudreau, J.D., Snell, L. & Steinert, Y. 2014, “Reframing Medical Education to Support Professional Identity Formation”, Academic medicine : journal of the Association of American Medical Colleges, .
Darbyshire, D. & Baker, P. 2013, “Encouraging new doctors to do medical education research”, The Clinical Teacher, vol. 10, no. 6, pp. 358-361.
Helmich, E., Bolhuis, S., Dornan, T., Laan, R. & Koopmans, R. 2012, “Entering medical practice for the very first time: emotional talk, meaning and identity development”, Medical education, vol. 46, no. 11, pp. 1074-1086.
Kuper, A., Nedden, N.Z., Etchells, E., Shadowitz, S. & Reeves, S. 2010, “Teaching and learning in morbidity and mortality rounds: an ethnographic study”, Medical education, vol. 44, no. 6, pp. 559-569.
Mayer, R.E. 2001, Multimedia Learning. Second edn, Cambridge University Press, New York.
Saleh, N. 2010, “The value of virtual patient in medical education”, Annals of Behavioural Science and Medical Education, vol. 16, no. 2, pp. 29-31.
Sweller J, van Merrienboer J, Paas F 1998, “Cognitive architecture and instructional design”, Educ Psychol Rev, , no. 10, pp. 251-296.
The Lancet 2013, “What is the purpose of medical research?”, The Lancet, vol. 381, no. 9864, pp. 347.