The results are presented in 3 parts. The first presents the opinions of influential figures related to research in medical education. The second concentrates on their views of factors that influence the production of knowledge. The last addresses the means that they consider relevant for raising the level of quality of research. We will discuss the results with reference to Bourdieu’s concept of field.
Opinions on research in medical education
The analysis of interviews reveals that a large majority of influential figures feel that research in medical education remains of insufficient quality despite progress realized over the course of the last 2 decades. Four major reasons were given in interviews for this judgment:
- Studies are often repetitive; and insufficiently contextualized with regard to the literature in medical education;
- The knowledge of researchers in the area of theory is limited;
- The works are opportunistic;
- The education of researchers in science, and more specifically in social science has gaps.
As we will see from their comments, respondents tend to be more on the production for producers pole.
The repetitive character of studies
For several influential figures, the insufficient quality of work in medical education is explained in part by the fact that researchers have a limited knowledge of the literature in their own field. This limited understanding has two important consequences: first, researchers have a tendency to repeat studies that have already been undertaken on similar subjects, and second, certain researchers have difficulties in justifying the originality of their work and showing how it contributes to the advancement of knowledge. The two following quotations illustrate the opinion of the majority of influential figures about the repetitive nature of studies:
A large number of works only reproduce what has already been done. These works do not add new knowledge. In my opinion there are certain questions that researchers should ask themselves before undertaking a research project, for example: ‘What is the state of knowledge of the subject I want to study?’ ‘Why is it important to undertake this research?’ ‘What new knowledge will this provide?’ For several researchers the posing of these questions already constitutes a challenge.
The second quotation addresses the “decontextualized” and fragmented character of work:
One of the limits of many research projects undertaken is the fact that they do not locate themselves in any context: there is no analysis which allows one to situate the study and there is no review of the literature which makes it possible to relate it to existing knowledge on the subject. Several researchers give the impression of working in a black box. This makes it difficult to advance knowledge in medical education. These studies, it seems to me, have difficulty in making a contribution in this regard.
Gaps in theoretical knowledge
A second judgment emerging from the analysis of the interviews is the observation that a number of studies in medical education contain gaps in theory. Several influential figures felt that these gaps interfere with development of research for 2 main reasons: on one hand they interfere with the creation of an integrated body of knowledge related to important problems, and on the other hand they limit the understanding of the factors and causes underlying observed phenomena. According to a number of respondents, the fact that researchers are unfamiliar with existing theories restricts their analysis of a phenomenon to a descriptive level.
Related to this observation, several influential figures felt that although research in medical education should have a utilitarian dimension, the research agenda is currently too strongly subordinated to the demands of educators and administrators. This subordination acts as a brake on the development of works of a theoretical nature or that target more fundamental questions. According to these individuals, the current production seems to be going in several disparate directions without being tied to any organizing principals or identifiable themes. The following excerpt illustrates this point of view:
While research in medical education must have a practical aspect, it is absolutely essential that it rests on fundamental theories because if not it becomes superficial and uninteresting. This is particularly true for research that aims to resolve problems. In fact, if there is no theory permitting the understanding of fundamental processes, how is it possible to predict and control for the effectiveness of interventions? If research in medical education continues to be only a free service for medical schools it risks becoming a functional activity as opposed to a true intellectual activity.
A third concerning characteristic of medical education research that was expressed by participants was the observation that a certain number of works in medical education are essentially opportunistic, that they arise from random situations or circumstances. The following commentary illustrates this position:
It is not unusual for researchers to undertake a research project only because there is a group of students available — this becomes their cohort — and a new course is given to them. The research consists of evaluating that course.
With little orientation toward longer-term knowledge building efforts, this type of research tends to remain on a small scale and focus on questions that are of greatest interest to the institution where they take place. According to our participants, these studies are difficult to generalize to all faculties of medicine and therefore are of questionable value as evidence for the development of other training programs.
Research in medical education has not addressed the truly “big questions”. The sampling is limited and the projects are always short-term. For example, there are no longitudinal studies addressing multiple faculties of medicine. The projects are often developed as a result of the available resources rather in relationships to issues that are worth studying.
Gaps in research training
A final element arising from the interviews touches on the education of researchers in the field. Several influential figures believe that certain researchers have gaps in their own education regarding research generally, and more specifically regarding research in the social sciences. A recurrent theme on this subject was the observation that certain researchers tend to use methods taken from clinical research, and in particular randomized trials, in the domain of social sciences, without questioning the implications of such a transfer. This practice has detrimental effects on the quality of research, in particular on qualitative research; which requires specific methodological competencies. The participants attributed this tendency to transpose methodologies from clinical research into medical education research to a lack of education of the researchers themselves. The following quotation illustrates the point-of-view of several respondents in this regard:
Several researchers in medical education do beginner research. They have been educated in medicine and some of them do clinical research. When they begin to become interested in medical education, often they have not had the necessary preparation to lead research projects. To make up for this gap, they have a tendency to transfer their understanding from the field of clinical research into the domain of medical education research.
Factors influencing research practices
Three principal factors were identified by our influential figures as explaining why research in medical education had been weak in these ways. These factors relate to the conditions of the researchers’ working environment, budgetary constraints in medical education research and the dominant conception of research in the medical environment.
In terms of working conditions, it was suggested that a key problem involves the fact that research units give priority to providing consultation service to their faculties of medicine. According to participants to our study, the primary role of these centers currently involves responding to the needs of medical schools in areas of medical training, contributing to the improvement of teaching, and supporting clinicians who wish to undertake research activities in education. This mandate constitutes an obstacle to the development of long-term theoretical work. The research undertaken in these units aims primarily to find solutions to problems or to evaluate the effects of an intervention, leaving little place for more theoretical work. The following quotation illustrates the point-of-view of several respondents in this regard:
Research in medical education is very applied because it is first and foremost seen as a tool of service for faculties of medicine. In fact, the primary reason for which [the faculty] supports centers for research in medical education is in order to respond to their needs in terms of medical education. Given these high expectations, researchers hardly have the time to distance themselves from the mandate given to them.
Further, a certain number of our participants argued that the medical community itself seems less receptive to works of a theoretical nature. According to these individuals, clinician educators have a vision of research that is primarily utilitarian and have a limited interest in the theoretical or fundamental dimension of scientific research. This disinterest also becomes an obstacle to the diversification of research in medical education. The following excerpt illustrates this perception:
The reason that theory has little importance in medical education comes from the fact the doctors give it little credibility. Doctors are not interested in listening to your theory of power or of influence for example. Certainly there are exceptions but for most part this is the reality. What they want to know is how they can make something more effective and cost less. They are not interested in understating the complexities of research, what they want are results. This practical attitude is generalized in the medical environment and it significantly influences research.
The second factor arising from the interviews to explain the gaps in theory and the opportunistic nature of the work is the lack of financial support for medical education research. Several influential figures underscored the fact that there are almost no granting agencies or programs of grants dedicated to support research in medical education. This absence requires researchers to rely on internal resources at their institution in order to undertake their research projects. Because these sources are generally limited and irregular, it is difficult for them to elaborate research programs rather than small-scale projects.
A third identified factor arises from the dominant conception of research in the medical environment in which medical education research is published. According to certain participants, this dominant conception is strongly inspired by a biomedical model of sciences which gives priority to a type of research practice and to publication formats that seem to be incompatible with the development and discussion of theoretical questions. This conception comes to life in the rules for editing articles, which, in certain cases, are perceived to be particularly constraining. The argument of one respondent illustrates the opinion of several influential figures on this subject:
Articles are always very short, extremely structured and predictable. What counts is methodology and results. The background, the discussion and the conclusion have a secondary importance.
Given that the biomedical model is the dominant model in the field of medical education research, as underlined by certain respondents, researchers have difficulty making other choices. If they want to receive recognition from their peers, they must conform. This model is valued by the majority of journals and constitutes the legitimate way of doing research and of reporting results. The journal Advances in Health Sciences Education was seen to differentiate itself somewhat from the other journals because it imposes no length restrictions on authors.
Two means to improve research in medical education
Finally, recognizing these problems and their sources, our participants identified two principal means to improve research in medical education. The first relates to intensifying the collaboration between holders of PhD’s and clinicians, given that the competencies of each group are complementary. While MD’s, as a result of their clinical educator role, are best placed to identify key practical questions to study, the PhD’s, because of their academic training and theoretical backgrounds, have the required competencies to enrich those practical questions with theoretical perspectives and contribute effectively to the development and enactment of the associated research projects. As one participant stated:
Research in medical education necessarily has to be done in collaboration. Many PhDs doing research in this domain don’t have any medical training and don’t do any medical training. Thus, it’s crucial for them to team up with physicians, because physicians are in a way the specialists when it comes to the specification of the research problem. PhDs’ contribution lies in the fact that they can set the problem in a theoretical context and frame it in a way that it contributes to the advancement of knowledge.
The second means envisioned by the influential figures to improve medical education research involved further diversifying the disciplines engaged in research in this area, with the goal of generating new questions and enlarging the perspectives on research. Several respondents indicated that they would value an approach to medical education research that gives a larger place to the social sciences. One participant stressed that research in medical education “need sociologists, anthropologists, economics, and historians, etc. to study the problems related to the training of physicians through innovative angles.”