importance of research in medical education

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• Published: 16 April 2019

Medical education today: all that glitters is not gold

• L. Maximilian Buja   ORCID: orcid.org/0000-0001-8386-7029 1  

BMC Medical Education volume  19 , Article number:  110 ( 2019 ) Cite this article

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The medical education system based on principles advocated by Flexner and Osler has produced generations of scientifically grounded and clinically skilled physicians whose collective experiences and contributions have served medicine and patients well. Yet sweeping changes launched around the turn of the millennium have constituted a revolution in medical education. In this article, a critique is presented of the new undergraduate medical education (UME) curricula in relationship to graduate medical education (GME) and clinical practice.

Medical education has changed and will continue to change in response to scientific advances and societal needs. However, enthusiasm for reform needs to be tempered by a more measured approach to avoid unintended consequences. Movement from novice to master in medicine cannot be rushed. An argument is made for a shoring up of biomedical science in revised curricula with the beneficiaries being nascent practitioners, developing physician-scientists --and the public.

Unless there is further modification, the new integrated curricula are at risk of produce graduates deficient in the characteristics that have set physicians apart from other healthcare professionals, namely high-level clinical expertise based on a deep grounding in biomedical science and understanding of the pathologic basis of disease. The challenges for education of the best possible physicians are great but the benefits to medicine and society are enormous.

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Introduction

The traditional medical education system widely adopted throughout most of the twentieth century has produced generations of scientifically grounded and clinically skilled physicians who have served medicine and society well. Yet sweeping changes launched around the turn of the millennium have constituted a revolution in undergraduate medical education (UME) and graduate medical education (GME) [ 1 , 2 , 3 ]. While continual assessment leading to measured adaptation is essential for the enduring value of a system, simultaneous and multifaceted change such as that occurring in the traditional medical education system qualifies as disruptive innovation [ 4 ]. The purpose of this article is to offer a critique and express a major concern by a physician-scientist, pathologist and medical educator that the contemporary medical education system is being subject to the downside of disruptive innovation with unintended and potentially detrimental long-term outcomes for academic medicine and clinical practice.

The past century in medical education

The education of a physician has developed to encompass pre-medical preparation, a course of study in a medical school which is typically a major component of an academic medical center (AHC), and medical specialty training in residency and fellowship programs, UME and GME, respectively [ 5 , 6 ]. This education provides the basis for a professional career enhanced by continuing medical education and life-long learning. Early in the twentieth century, medical education became guided by principles articulated by Abraham Flexner and William Osler. Flexner recommended that medical schools should be university based, have minimum admission requirements, implement a rigorous curriculum with applied laboratory and clinical science content, and have faculty actively engaged in research [ 5 , 7 ]. Osler championed bedside teaching, bringing medical students into direct contact with patients, and learning medicine from these direct experiences under the guidance of faculty clinicians [ 7 , 8 ]. The result was the establishment of two key components or pillars of medical education, namely, the basic or foundational sciences and the clinical sciences [ 2 ]. The two-pillar model of medical education provided the conceptual basis for a four-year UME curriculum comprising biomedical science courses in the pre-clinical years and clinical clerkships in the clinical years. Medical schools utilizing this construct produced scientifically grounded physicians capable of a high level of clinical practice as well as a subset who pursued highly successful careers as physician-scientists and academicians [ 9 ].

AHCs and healthcare system

A fundamental element in the achievement of medical schools in the twentieth century was the development of medical education as a public trust and social contract between the medical schools and society [ 5 ]. However, in-depth analysis of the history of medical education has shown that it is inextricably intertwined with healthcare delivery and broader societal norms [ 5 , 6 , 7 ]. UME and much of GME take place in academic health centers (AHC), which must function in the world of healthcare delivery [ 10 ], and are subject to the complexities of the associated health care system in which they operate, including the fragmented American healthcare system [ 11 , 12 , 13 , 14 ].

Calls for curriculum reform and restructuring

In this context, discontent among academics and professional organizations concerning the traditional medical education construct has accelerated in recent years [ 1 , 2 , 3 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. Both the teaching methodology and the content of the established curriculum have come under severe criticism. Calls have been made repeatedly for the cultivation of a different type of physician more attuned to and equipped for practice in the current healthcare scene [ 15 , 16 , 17 , 18 , 19 , 20 ].

Reform movement and integrated curriculum

To promote more active learning and less passive learning, curriculum developers have introduced a variety of approaches, including small group sessions, problem-based learning, self-directed learning, team-based learning, and flipped classrooms as replacements for the traditional lecture format [ 21 ]. However, many in the reform movement consider that pedagogical reform, while necessary, must be joined by content reform to develop the requisite skill set in future practitioners of medicine [ 15 , 16 , 17 , 18 , 19 , 20 ]. As a result, there has been a movement in mass toward adoption of a radically redesigned curriculum as a third wave, post-Flexnerian approach to medical education [ 1 , 2 ]. A major goal of the curriculum reformers is to produce physicians who can deliver an individualized plan of care that reflects the physician’s mastery of basic physiology, awareness of the best current evidence, skillful patient communication, and shared decision-making [ 20 ].

The ideal of the post-Flexnerian third wave is a fully integrated curriculum in place of the traditional curriculum comprised of a distinct pre-clinical component with subject-based courses and a subsequent clinical component [ 22 ]. Initial implementation involves partial integration comprising horizontal integration defined as integration across disciplines but within a finite period of time and vertical integration representing integration across time with breakdown of the traditional barrier between basic and clinical sciences. A fully integrated curriculum is characterized by spiral integration encompassing both horizontal and vertical integration combining integration across time and across disciplines [ 22 ].

This revised design also includes added content addressing broader issues constituting “Health Systems Science” as a third pillar of medical education co-equal with basic and clinical medical sciences [ 23 , 24 , 25 , 26 ]. Topics include population health, health policy, healthcare delivery systems, and interdisciplinary care. A correlate is the replacement of the biomedical model of health and disease with a broader biopsychosocial model of health, disease and the patient-physician relationship [ 23 , 27 ].

A related development is the implementation of the new MCAT that aims to balance testing in the natural sciences with testing in the social and behavioral sciences and assessing critical analysis and reasoning skills. The redesign is based on the premise that tomorrow’s physicians need broader skills and knowledge than in the past [ 28 ]. Medical education reform also includes heavy emphasis on professionalism and professional identity development [ 29 ]. The reforms also are aimed at achieving a more coherent continuum of medical education [ 30 ]. My institution, McGovern Medical School of The University of Texas Health Science Center at Houston, embarked on the path of curriculum restructuring in 2013 and has instituted such a redesigned curriculum beginning in 2016 [ 31 ].

Influence of oversight bodies

Advances in medical care and technology have been driving forces behind these curriculum changes. In the United States, a major impetus for such curriculum changes has come from the Liaison Committee for Medical Education (LCME), and its sponsoring institutions, the American Association of Medical Colleges (AAMC) and the American Medical Association (AMA), and the Accreditation Council for Graduate Medical Education (ACGME) (more accurately, thought leaders in these organizations) [ 32 ]. Regulatory bodies in other countries have had similar roles [ 22 ]. Curriculum reformers have used the imperative of actual and perceived expectations of the LCME as a driver of curriculum revision.

Characteristics of Today’s medical students

A major consideration in any discussion of education is the profile of the students. Analysis of today’s students is that they score higher on assertiveness, self-liking, narcissistic traits, high expectations, and some measures of stress, anxiety and poor mental health, and also lower on self-reliance [ 33 , 34 , 35 ]. These generational characteristics are rooted in shifts in culture and reflect changes in society. These character traits are clearly established by the time students enter medical school.

Notable individual exceptions reinforce the average characteristics of today’s students which have definite positive aspects, such as the focus on the individual, but also some negative consequences [ 33 , 34 , 35 ]. Motivation can become dysfunctional so that high levels of dedication to a previously enjoyed activity can result in burnout. Burnout is alarmingly high among today’s medical students and residents [ 36 , 37 ]. Burnout is a psychosocial syndrome that is associated with motivational, performance and psychological difficulties. Perfectionism, defined as a combination of high standards and high self-criticism, is also on the rise [ 38 , 39 ]. The two may compound each other.

The characteristics of today’s medical students including their strengths and vulnerabilities, present special challenges for faculty engaged in their education [ 40 , 41 , 42 , 43 ]. Notably, while these students have high I.Q.s, they typically show little desire to read long texts [ 33 ]. The implication for educational design (pedagogy) is that these students likely benefit from a structured but also more interactive learning experience and that instruction may need to be delivered in shorter segments and perhaps incorporate more material in media such as videos and an interactive format. But, even when the classroom hour is used for so-called active learning approaches, such as the flipped classroom, attendance is still often poor. There has been a proliferation of commercial products, including First Aid, Firecracker, Osmosis and Pathoma, that attract students with shortcut approaches, including flashcards and videos, for passing standardized tests [ 44 ]. These products cater to the study habits of many of today’s students. Many of today’s medical students are opting for elective perusal online of previously recorded lectures and the use of various previously mentioned study aids while minimizing direct classroom interaction with professors [ 45 ].

General critique

While apparently accepting the practices of today’s medical students as a fait accompli , a key tenant of the reform movement is that the traditional subject-based and lecture-based curriculum has failed to accomplish the desired outcome of producing physicians for the twenty-first century [ 20 ]. Content reformers favor a repeal of major parts of the traditional UME curriculum to make room for the lessons that are aimed at allowing students to develop skills in modern clinical reasoning and decision-making. Major goals of integration are to break down barriers between the basic and clinical sciences and to promote retention of knowledge and acquisition of skills through repetitive and progressive development of concepts and their applications [ 22 ].

Reformers recognize that implementation of the new curriculum requires trade-offs and hard choices. They have clearly articulated that topics such as clinical decision-making, comparative effectiveness and other Health Systems Science topics must take priority over the depth of basic science content presented in traditional courses [ 20 ]. The argument is made that major revamping of basic science in the curriculum is acceptable because of perceived major overlap and repetition among traditional basic science courses. There also is the often unstated but implied view that traditional basic science courses burden medical students with excessive and unnecessary detail. While strong emphasis is placed on integrating basic science courses and providing clinical experiences early in the curriculum, the extension of basic science content into the clinical years has been identified as a major challenge and a major shortcoming of integrated curricula [ 22 , 46 ].

The first two years of the UME curriculum is the only time in the entire professional career of a physician when the fundamentals of biomedical science and the clinical skills of history taking and physical examination intersect coherently, and are formally taught and learned. A background in factual knowledge and relationships among facts is crucial for critical thinking and evidence-based decision-making in medicine [ 46 , 47 , 48 , 49 ]. Studies have shown that factual knowledge of medical science is essential for the development of clinical skill [ 46 , 47 , 48 , 49 , 50 ]. Clinical knowledge is gained from the integration of conceptual knowledge (facts, “what” information), strategic knowledge (“how” information) and conditional knowledge (“why” information) [ 49 ]. There is no short cut here; a certain amount of memorization and with some repetition is required. It is counterproductive to dilute the learning experience of the core material in the pre-clinical years by substituting other topics that are best learned after a foundation is laid and its strength tested through the crucible of clinical practice.

Competency-based education: time-based versus competency-based medical education and accelerated medical education

Momentum has continued to grow for demonstration of a set of competencies rather than cognitive knowledge alone as the primary outcome of UME as well as GME. The movement toward outcomes and competency-based education in UME was presaged by a focus on innovation in GME, which led to the introduction by the Accreditation Council for Graduate Medical Education (ACGME) of the six competencies as key elements in residency training programs [ 51 , 52 ]. Change in the world of GME was compounded by the introduction of the duty hour requirements at about the same time [ 53 ]. The ACGME has moved further along the path of competency-based training with the introduction of milestones as a focus of the new accreditation system (NAS) [ 54 , 55 ]. Competencies also have been linked to Entrustable Professional Activities [ 56 ].

Some are taking the competency construct further by promoting time variable criteria for the granting of the medical degree as well as certification in medical specialties following a period of graduate training [ 57 , 58 , 59 , 60 , 61 , 62 ]. Others are promoting an accelerated three-year UME program [ 63 ].

All would agree that the goal of medical education is to produce competent physicians. However, the educational approach embodied in competence-based curricula for highly skilled professions including medicine versus lower level occupations has been found to be philosophically questionable, methodologically complex and highly controversial [ 64 , 65 ]. The logistics of implementing such programs are daunting and represent another major draw on faculty time to provide evaluation of the ascertainment of the set of competencies and entrustable professional activities (EPAs) of the learners [ 56 , 66 ]. A more feasible approach would be to maintain fixed time programs but allow accelerated advancement coupled with opportunities for dual degrees, pursuit of research, and other projects [ 67 ].

Arguments in favor of reduction of UME to a 3 year program include increased production of physicians to meet the shortage and reduction of student debt. The current interest in some quarters for a 3 year program represents the third time in the last century this idea has been promoted [ 64 ]. This third wave will have to face many of the same issues that affected the previous two attempts.

Impact of student evaluation systems

How students function in an educational program is inextricably linked to how they are evaluated. Recurrent movements to abolish grades, exams and honor societies to mitigate undue competiveness, stress and general malaise is the present educational zeitgeist [ 68 , 69 , 70 , 71 , 72 ]. For many years, the standard system of student evaluation was based on numerical grades in every course and led to a cumulative numerical score and class ranking. As a component of disruptive innovation, some medical schools have completely abolished grades and implemented pass-fail systems. However, most medical schools, including some who have tried the purely pass-fail approach, have arrived at a system of Honors, High Pass, Pass, Marginal Pass and Fail -- essentially the A through F system used in K-12 education [ 73 ].

This has led to the rise of the exaggerated importance of United States Medical Licensing Exam (USMLE) scores, particularly, USMLE Step 1 scores, as the major or sole objective evaluation of cognitive achievement of medical students. Proponents argue that the new curricula are successful because students are performing at least as well on USMLE Step 1 as they did in the old curricula, and that they do as well in pass-fail systems as in systems with grades [ 68 , 69 , 70 , 71 , 72 ]. However, these advocates, in essence, are contributing to the perpetuation of the undue importance of USMLE Step 1.

An undue emphasis on a single high stakes summative evaluation creates a dilemma for medical educators and students [ 73 ]. An excessive focus develops on preparing students for the USMLE Step 1 examination and “teaching to the test” [ 20 , 74 ]. This milieu is counterproductive to in depth assimilation of subject matter in the biomedical sciences. Unintended consequences in multiple domains include conflict with holistic undergraduate medical education admission practices, student well-being, and medical curricula.

Medical students have become increasingly aware of the “USMLE issue.” In an Invited Commentary, medical students from various institutions across the country have reflected on their shared experiences and have postulated that the emphasis on USMLE Step 1 for residency selection has fundamentally altered the preclinical learning environment, creating a “Step 1 climate” [ 44 ]. They have commented on how the Step 1 climate negatively impacts education, diversity, and student well-being, and they have urged a national conversation on the elimination of reporting Step 1 numeric scores. Educators also have articulated similar recommendations regarding making the USMLE results reporting as pass/fail [ 75 , 76 ]. But concern has also been voiced that pass/fail can be a disincentive to motivation for broad knowledge acquisition. Also, the development of an alternate, more holistic standardized metric by which to compare students’ applications for residency positions has been proposed but is currently not operative [ 74 ].

The movement away from meaningful grades for medical school courses also has led to an increasingly elaborate subjective evaluation in “dean’s letters” [ 77 , 78 ]. The AAMC has introduced the Medical Student Performance Evaluation (MSPE) as a refinement of the “dean’s letter.” Approaches to evaluation of student performance generally involve formative and summative exams in the pre-clinical years, and subject exams coupled with faculty assessment of performance, in the clinical clerkships. Then, these evaluations (honors, high pass, pass, etc.) are integrated into lengthy MSPEs or dean’s letters that provide commentary and largely subjective impressions. In spite of the AAMC guidelines of comparative information about applicants be included, dean’s letters or MSPEs often continue to lack specificity regarding student performance [ 77 , 78 ]. Major emphasis continues to rest on USMLE scores for the granting of interviews and ranking of applicants by residency program selection committees [ 74 ].

A second influential criterion relied upon in resident candidate ranking and selection is election to the Alpha Omega Alpha (AOA) Honor Society from the top one-sixth of the class. Election into AOA has long been a motivator for student performance. A relationship between AOA membership and selection into highly competitive residencies is well known [ 79 ]. AOA is receiving criticism that membership is not reflecting the balance of diversity of the student body [ 80 , 81 ]. But, I hold that AOA must maintain a focus on excellence [ 82 ].

The grade abolition movement misses the reality of competition in human affairs. I think that the dilemmas about the “USMLE issue” can be diffused by a return to providing meaningful grades for medical school courses and an overall summative evaluation for the four years of medical school. (My definition of meaningful grades encompasses either numerical or letter grade equivalents which reflect actual performance relative to other students and objective norms.) Students must compete and excel to gain admittance into medical school. This shouldn’t be any different when students are training to be physicians. Safeguards can be put in place to deal with excess competition [ 33 ]. Nevertheless, competition within bounds promotes excellence. I strongly concur with the view that medicine is based on being a meritocracy and needs to remain a meritocracy [ 82 , 83 ].

Impact on medical educators

Over the years, medical educators, including basic biomedical science educators and clinician educators, have had to adapt to changes in curriculum [ 84 , 85 , 86 ]. Many medical educators have experienced significant challenges in the implementation of the new curriculum [ 87 ]. Competing demands on faculty time are causing stress and burnout among faculty as well as learners. A curriculum heavily geared to small group teaching places further considerable demand on faculty time. A significant inverse relationship has been found between faculty members’ readiness to change teaching approaches and their severity of burnout [ 87 ].

The educational mission itself can be enhanced by the recognition of foundational principles for teaching and education [ 88 ]. At Johns Hopkins University School of Medicine, a formal review process has led to the articulation of 10 foundational principles or characteristics of a medical educator [ 88 ]. Each principle addresses an important theme in the educational mission. These principles include specific recognition of the importance of being a role model and the responsibility to develop the next generation of physicians (Table  1 ).

Ethics, professionalism and inter-professionalism in the curriculum

A major goal of the new curriculum is the development of holistic, ethical physicians with clear communication skills imbued with empathy and compassion for patients [ 29 ]. These goals are not new but are imbedded in the ideals of the medical profession which are intrinsic to its code of ethics [ 89 ]. There is a longstanding consensus that professionalism and professional identity formation need to be key elements of medical education [ 29 ]. However, a unifying theoretical or practical model to integrate the teaching of professionalism into the medical curriculum has not emerged [ 90 , 91 ]. Nevertheless, role modeling and personal reflections -- ideally guided by faculty -- rather than blocks of time devoted to didactic exercises -- are widely held to be the most effective techniques for developing professionalism [ 90 , 91 ]. Inter-professional education, another major contemporary thrust, also is best addressed after a foundation in the biomedical sciences is developed [ 92 ].

Regarding the issue of classroom attendance, medical student and teaching faculty attitudes have been found to differ regarding the importance of classroom attendance and its relationship to professionalism, findings that were at least partially explained by differing expectations of the purpose of the preclinical classroom experience [ 45 ]. Students tended to view class-going primarily as a tool for learning factual material, whereas many faculty viewed it as serving important functions in the professional socialization process [ 45 ]. Rather than dealing with practical solutions to enhancing the value of lectures, other formats are promoted which place inordinate demands on faculty time. This scenario is off-kilter. It sends the wrong messages to students regarding personal responsibility and professionalism. A practical approach to dealing with differing expectations and to effectively instill professionalism is to provide students, residents and staff with a written list of expected behaviors coupled with teaching and role modeling, assessment and remediation [ 93 ].

Impact on pathology

Pathology is uniquely both a medical science and a clinical discipline [ 94 , 95 , 96 , 97 , 98 , 99 ]. In the analogy of the tree of medicine, the trunk is general pathology, which draws from all the basic biomedical sciences to elucidate general principles of regulation and dysregulation of homeostasis, and divides into the many branches of special pathology (organ system pathology); each one of these branches supports a specialized field of clinical medicine [ 95 ]. Thus, the place of pathology in the curriculum is seminally important in linking the basic biomedical sciences to clinical medicine and providing an understanding of the pathobiological basis of disease. The Association of Pathology Chairs has put forward a position paper on pathology competencies for medical education [ 99 ]. Since a solid understanding of pathology is core to the practice of medicine in any specialty, the position paper posits that all medical students must learn the basic mechanisms of disease, their manifestations in major organ systems, and how to apply that knowledge to clinical practice for diagnosis and management of patients. However, the place given to the pathobiological basis of disease in the new curriculum models is diminished.

Although a traditional curriculum includes a formal pathology course, pathology has been disadvantaged by the fact that students generally have little exposure to pathology or pathologists in the professionally formative clerkship years [ 100 , 101 , 102 ]. However, a distinction needs to be made between student perceptions of pathology as a career and pathology as a critically important medical science. The task of grounding medical students in principles of pathology, including pathogenesis and pathophysiology of disease, has been made considerably more difficult by the design of the new integrated, modular curriculum. The resultant discontinuance of pathology courses and their replacement by elements of pathology scattered episodically in the pre-clinical years likely has resulted in the dilution of core scientific principles and has contributed to a reduced understanding and interest in pathology [ 100 , 101 , 102 ].

Initiatives to increase the exposure and understanding of pathology and the autopsy are necessarily going to be tailored to the local environment operative at each institution [ 100 , 101 , 102 , 103 , 104 , 105 ]. While these approaches cannot fully substitute for the coherent presentation of the pathobiological basis of disease in a pathology course, it is imperative that pathology educators make this effort.

Nevertheless, exposure of medical students to the autopsy is a casualty of the current environment [ 106 , 107 , 108 , 109 ]. As a consequence, it is disconcerting but hardly surprising that physicians now in residency training and clinical practice have little understanding or appreciation for the autopsy, and, therefore, have little motivation for or experience with discussion of the autopsy with next of kin of the deceased. This state of affairs is contributing to the decline of the autopsy, which remains a uniquely important procedure for quality assurance in medicine [ 108 , 109 ].

Another correlate of the current undergraduate medical educational environment is that pathology now has the lowest percentage of residency positions filled by U.S. seniors in the National Residency Matching Program [ 110 , 111 ]. Furthermore, pathology residency programs have joined other medical specialties in conducting “boot camps” for incoming trainees [ 112 , 113 , 114 ]. The boot camps are aimed at providing the basics of a necessary foundation in pathology-specific medical science and in introducing basic skills and processes required for practice of anatomic pathology and laboratory medicine [ 112 ]. The assessment of pathology educators is that the new LCME-driven curriculum is producing a medical graduate who may think differently, but certainly lacks subject-specific knowledge for a variety of medical specialties. A putatively superior curriculum should not present a need for remedial learning for its graduates. Hopefully, boot camps for pathology trainees will be more effective than appears to be the case for bootcamps for trainees in surgical specialties [ 114 ].

Impact on physician-scientists

Physician-scientists of various stripes have a unique and important role in translating basic science discoveries into advances in clinical medicine [ 115 , 116 ]. Their numbers are small and their development is under threat. In some institutions, tailored curricula are being implemented to promote the development of clinician scientists [ 117 , 118 ]. Nevertheless, there is a legitimate concern that the diminished position of basic science in the new curriculum is detrimental to the future maturation of physician-scientists [ 119 ].

Early predictors of career achievement in academic medicine have been identified as: 1) membership in AOA, 2) rank in the top third of the graduating class, and 3) research experience in medical school [ 9 ]. These three factors were of crucial importance in launching my career as was the seminal importance of a faculty mentor [ 120 , 121 ]. The new curricula need to ensure that such opportunities are available for motivated medical students.

Complexities and proposed solutions

Reformers contend that changes in the healthcare system and in medical practice in the clinic and hospital have outpaced those in the classroom, resulting in a declining relevance of the traditional curriculum and a growing urgency for a paradigm shift in medical education. Three barriers to the implementation of evidence-based curriculum reform have been identified [ 20 ]. First, curriculum revision must take place within a certain time frame, making it a zero-sum game. Second, transitioning from a few basic scientists lecturing entire classes from the podium to numerous small groups often tutored by clinical faculty dramatically increases the teaching demands on all faculty and especially faculty clinicians. Third, an inevitable tension is created between a holistic educational approach and the imperative to prepare students for USMLE Step 1.

Regarding the first point, reformers contend that reduction and revamping of the basic science content is warranted and can be achieved by elimination of perceived redundancy in the old curriculum. But the reality is that biomedical science, both in terms of curriculum time and emphasis, has been diminished in the new curricula [ 102 , 118 , 119 ]. Further negative pressure on the basic sciences is coming from the initiative to incorporate Health Systems Science into the curriculum with associated need to develop faculty with skills in teaching this material [ 23 , 24 , 25 , 26 , 27 ].

Pertinent to the second point, there are special challenges for faculty in educating the current generation of medical students in the Information Age [ 33 , 40 , 41 , 42 ]. Certainly faculty educators need to recognize the characteristics of today’s students and take this into consideration in implementation of the curriculum. However, rather than taking a laissez faire approach, faculty educators need to set expectations regarding standards of performance [ 93 ]. In medical education, it is vital that faculty and staff temper overconfidence and excessive risk-taking [ 33 ]. Pedagogical approaches can be modified to meet the learning pattern of today’s medical students, for example, by blending lecture and non-lecture formats [ 43 ]. Nevertheless, standards for content and learning should remain the same; educators cannot compromise on the material that must be learned [ 33 ]. Also, medical students need to be taught and experience functioning and decision making in the face of inevitable uncertainties in life and medical practice [ 122 , 123 ].

Regarding the third point, neo-curriculum advocates contend that solutions to the dilemma of the usurpation of the curriculum by the USMLE lie outside the control of undergraduate medical educators [ 20 ]. These advocates say that solutions require creativity and action from residency selection committees and the USMLE’s sponsors, the Federation of State Medical Boards and the National Board of Medical Examiners, because of the implementation of the new UME curriculum. But those in control of the UME curriculum can ensure that meaningful objective summative assessments of students in both pre-clinical and clinical courses are included in dean’s letters so that the USMLE is not the sole or primary objective assessment presented to residency selection committees.

In spite of the complexities, I contend that rebalancing the position of medical science in the medical educational curriculum has paramount importance [ 46 , 47 , 48 , 49 , 50 , 102 , 119 ]. This is to be achieved by providing the necessary amount of unencumbered space freed of major competing priorities. Different schools may use different approaches. Nevertheless, I favor restoration of subject-based courses, including a pathology course. Appropriate coordination of subject matter among the courses is essential, but this does not require the modular integration approach. Optimal ways of integrating topics in Health Systems Science during the multiyear curriculum need to be developed such as not to unduly compete with education in the core medical sciences.

Trends in American healthcare, academic medical centers and academic medicine

Contemporaneous with restructuring of medical education, medical practice has undergone a fundamental transformation, dominated by a fixation on increasing efficiency in the delivery of care with quality of care a secondary consideration [ 124 , 125 ]. The standard for the medical product has become good enough rather than excellent.

Regarding academic medicine, from 1985 to 2008, the percentage of active doctors engaged in teaching, research or administration decreased from 9 to 5.5%, and the number of teachers and mentors per US medical graduate declined from 0.11 to 0.07 [ 124 , 125 ]. During the decade prior to 2004, biomedical research funding from all sources in America increased at an annual rate of 6.3%, and the United States funded more than half of all biomedical research conducted throughout the world. Since 2004, the growth rate for research funding has decreased to 0.8%, and the U.S.’ share of the world’s research investment has decreased to 44%. From 1996 to 2014, the percent of Nobel laureates in medicine or physiology who were at US institutions at the time of the award decreased from 80 to 45% [ 124 , 125 ].

These very disturbing trends underscore some of the final words of the noted astrophysicist, Stephen Hawking, who warned that education and science around the world are “in danger now more than ever before” [ 126 ].

As eloquently stated by Brigham and Johns, the essence of excellence in medicine is more than doing what we know to do well, but must include a commitment to discovering what will make the better possible, and a dedication to perpetuating the best of the profession [ 125 ]. I content that countering the very disturbing trends just described is going to require a major multifaceted effort including a renewed commitment to advocacy for education and science and the rigorous education of new scientifically grounded physicians and physician-scientists who can carry the torch forward.

The essence of a physician

As articulated over 100 years ago, the characteristics of the ideal physician extend to personal life, professional life and public life [ 127 ]. There is a broad consensus that the good doctor manifests a combination of humanistic and scientific attributes and capabilities [ 128 , 129 ]. Seven key roles of the ideal doctor have been identified as communicator, collaborator, manager, health advocate, scholar, professional, and the integrating role of medical expert. Importantly all the roles overlap equally to create the ‘Medical Expert’ [ 130 , 131 ]. Movement from novice to master in medicine (medical expert) cannot be rushed. Time, experience –and yes, repetition -- is necessary for maturation. This maturation needs to be built on a solid foundation in biomedical science and the pathobiology of disease. The time and place to inculcate the core of this foundation is the first two years of the UME. There are many years for learning and perfecting clinical skills and evidence-based medicine. This will not happen effectively without a sound foundation in biomedical science. A byproduct of a restoration of a strong medical science curriculum will be a boost to the development of future generations of physician-scientists. Conversely, the combination of educational deficiencies coupled with lifestyle preferences carries the risk of diminishing the status of future physicians [ 33 ].

Enthusiasm for reform needs to be tempered by a more cautious and realistic approach. Unless there is modulation, the new curriculum is at risk of producing graduates deficient in the characteristic which have set physicians apart from other healthcare professionals, namely superior clinical expertise based on a deep grounding in biomedical science and understanding of the pathobiology of disease. Physicians need to remain the preeminent medical experts who strongly rely on understanding of basic mechanisms, particularly in dealing with difficult cases [ 47 , 48 , 49 ].

The overarching goal of medical education is the imparting of the highest principles, knowledge and skills in the nascent physician -- not bending medical education to follow prevalent but counterproductive personal and cultural trends. Our society requires physicians who will not just fit into the current dysfunctional American healthcare system but rather work to change it [ 11 , 12 , 13 , 14 ].

Medicine is a field that attracts people who want to have an impact, and this desire can be harnessed to improve medical education. The character traits of today’s medical students can potentially be harnessed to good ends, such as helping others through medicine. Good medical education resembles evolution in that it advances by ensuring the advancement of the fittest, including the fittest of the current generation of medical students just as the fittest of previous generations have succeeded in the past [ 33 , 82 , 83 ]. The challenges for education of the best possible physicians are great but the benefits for medicine and society are enormous.

Into the future, medical education Quo Vadis?

Abbreviations

American Association of Medical Colleges

Accreditation Council for Graduate Medical Education

Academic health center

American Medical Association

Alpha omega alpha honor medical society

Entrustable professional activity

• Graduate medical education

Liaison Committee for Medical Education

Medical college aptitude test

Medical Student Performance Evaluation

New accreditation system

• Undergraduate medical education

United States Medical Licensing Examination

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Buja, L.M. Medical education today: all that glitters is not gold. BMC Med Educ 19 , 110 (2019). https://doi.org/10.1186/s12909-019-1535-9

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Importance of research in medical education

Doctors are expected to apply recent insights from research to improve patient care. This is one of the reasons for integrating research into medical education. Mayke Vereijken (ICLON) concludes in her thesis that students experience engagement in research in different ways in their education. Defence on May 22, 2018.

From earlier studies in higher education, we know that both the way in which lecturers involve students in learning activities, and the way in which students perceive the learning environment influence learning. Student perceptions of research and opinions about learning and research could also change during the course.

Enhancing student engagement with research

The study programme can promote different aspects of student engagement in research in medical education, namely

• critical reflection on research findings;
• taking note of the research of teachers;
• student motivation for research;
• student participation in research;
• research-related learning outcomes such as student products and test scores on national progress tests in the medical scientific research domain.

A good curriculum design that supports coherence between different research practices can increase the involvement of students. For example, through learning activities in which students integrate their experiences with research in education and their views on the relevance of research during their studies.

Enhancing learning

Students seem to find research in education particularly stimulating for their own learning process, and less for medical professional practice. That is why relationships between research, education and patient care have to be made clear, both in the education of students and in medical follow-up courses.

Prior to the PhD defence of Mayke Vereijken, a seminar is held on research-based education and student involvement.

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Clarifying the Research Purpose

Methodology, measurement, data analysis and interpretation, tools for evaluating the quality of medical education research, research support, competing interests, quantitative research methods in medical education.

Submitted for publication January 8, 2018. Accepted for publication November 29, 2018.

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John T. Ratelle , Adam P. Sawatsky , Thomas J. Beckman; Quantitative Research Methods in Medical Education. Anesthesiology 2019; 131:23–35 doi: https://doi.org/10.1097/ALN.0000000000002727

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There has been a dramatic growth of scholarly articles in medical education in recent years. Evaluating medical education research requires specific orientation to issues related to format and content. Our goal is to review the quantitative aspects of research in medical education so that clinicians may understand these articles with respect to framing the study, recognizing methodologic issues, and utilizing instruments for evaluating the quality of medical education research. This review can be used both as a tool when appraising medical education research articles and as a primer for clinicians interested in pursuing scholarship in medical education.

Image: J. P. Rathmell and Terri Navarette.

There has been an explosion of research in the field of medical education. A search of PubMed demonstrates that more than 40,000 articles have been indexed under the medical subject heading “Medical Education” since 2010, which is more than the total number of articles indexed under this heading in the 1980s and 1990s combined. Keeping up to date requires that practicing clinicians have the skills to interpret and appraise the quality of research articles, especially when serving as editors, reviewers, and consumers of the literature.

While medical education shares many characteristics with other biomedical fields, substantial particularities exist. We recognize that practicing clinicians may not be familiar with the nuances of education research and how to assess its quality. Therefore, our purpose is to provide a review of quantitative research methodologies in medical education. Specifically, we describe a structure that can be used when conducting or evaluating medical education research articles.

Clarifying the research purpose is an essential first step when reading or conducting scholarship in medical education. 1   Medical education research can serve a variety of purposes, from advancing the science of learning to improving the outcomes of medical trainees and the patients they care for. However, a well-designed study has limited value if it addresses vague, redundant, or unimportant medical education research questions.

What is the research topic and why is it important? What is unknown about the research topic? Why is further research necessary?

What is the conceptual framework being used to approach the study?

What is the statement of study intent?

What are the research methodology and study design? Are they appropriate for the study objective(s)?

Which threats to internal validity are most relevant for the study?

What is the outcome and how was it measured?

Can the results be trusted? What is the validity and reliability of the measurements?

How were research subjects selected? Is the research sample representative of the target population?

Was the data analysis appropriate for the study design and type of data?

What is the effect size? Do the results have educational significance?

Fortunately, there are steps to ensure that the purpose of a research study is clear and logical. Table 1   2–5   outlines these steps, which will be described in detail in the following sections. We describe these elements not as a simple “checklist,” but as an advanced organizer that can be used to understand a medical education research study. These steps can also be used by clinician educators who are new to the field of education research and who wish to conduct scholarship in medical education.

Steps in Clarifying the Purpose of a Research Study in Medical Education

Literature Review and Problem Statement

A literature review is the first step in clarifying the purpose of a medical education research article. 2 , 5 , 6   When conducting scholarship in medical education, a literature review helps researchers develop an understanding of their topic of interest. This understanding includes both existing knowledge about the topic as well as key gaps in the literature, which aids the researcher in refining their study question. Additionally, a literature review helps researchers identify conceptual frameworks that have been used to approach the research topic. 2  

When reading scholarship in medical education, a successful literature review provides background information so that even someone unfamiliar with the research topic can understand the rationale for the study. Located in the introduction of the manuscript, the literature review guides the reader through what is already known in a manner that highlights the importance of the research topic. The literature review should also identify key gaps in the literature so the reader can understand the need for further research. This gap description includes an explicit problem statement that summarizes the important issues and provides a reason for the study. 2 , 4   The following is one example of a problem statement:

“Identifying gaps in the competency of anesthesia residents in time for intervention is critical to patient safety and an effective learning system… [However], few available instruments relate to complex behavioral performance or provide descriptors…that could inform subsequent feedback, individualized teaching, remediation, and curriculum revision.” 7  

This problem statement articulates the research topic (identifying resident performance gaps), why it is important (to intervene for the sake of learning and patient safety), and current gaps in the literature (few tools are available to assess resident performance). The researchers have now underscored why further research is needed and have helped readers anticipate the overarching goals of their study (to develop an instrument to measure anesthesiology resident performance). 4  

The Conceptual Framework

Following the literature review and articulation of the problem statement, the next step in clarifying the research purpose is to select a conceptual framework that can be applied to the research topic. Conceptual frameworks are “ways of thinking about a problem or a study, or ways of representing how complex things work.” 3   Just as clinical trials are informed by basic science research in the laboratory, conceptual frameworks often serve as the “basic science” that informs scholarship in medical education. At a fundamental level, conceptual frameworks provide a structured approach to solving the problem identified in the problem statement.

Conceptual frameworks may take the form of theories, principles, or models that help to explain the research problem by identifying its essential variables or elements. Alternatively, conceptual frameworks may represent evidence-based best practices that researchers can apply to an issue identified in the problem statement. 3   Importantly, there is no single best conceptual framework for a particular research topic, although the choice of a conceptual framework is often informed by the literature review and knowing which conceptual frameworks have been used in similar research. 8   For further information on selecting a conceptual framework for research in medical education, we direct readers to the work of Bordage 3   and Irby et al. 9  

To illustrate how different conceptual frameworks can be applied to a research problem, suppose you encounter a study to reduce the frequency of communication errors among anesthesiology residents during day-to-night handoff. Table 2 10 , 11   identifies two different conceptual frameworks researchers might use to approach the task. The first framework, cognitive load theory, has been proposed as a conceptual framework to identify potential variables that may lead to handoff errors. 12   Specifically, cognitive load theory identifies the three factors that affect short-term memory and thus may lead to communication errors:

Conceptual Frameworks to Address the Issue of Handoff Errors in the Intensive Care Unit

Intrinsic load: Inherent complexity or difficulty of the information the resident is trying to learn ( e.g. , complex patients).

Extraneous load: Distractions or demands on short-term memory that are not related to the information the resident is trying to learn ( e.g. , background noise, interruptions).

Germane load: Effort or mental strategies used by the resident to organize and understand the information he/she is trying to learn ( e.g. , teach back, note taking).

Using cognitive load theory as a conceptual framework, researchers may design an intervention to reduce extraneous load and help the resident remember the overnight to-do’s. An example might be dedicated, pager-free handoff times where distractions are minimized.

The second framework identified in table 2 , the I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver) handoff mnemonic, 11   is an evidence-based best practice that, when incorporated as part of a handoff bundle, has been shown to reduce handoff errors on pediatric wards. 13   Researchers choosing this conceptual framework may adapt some or all of the I-PASS elements for resident handoffs in the intensive care unit.

Note that both of the conceptual frameworks outlined above provide researchers with a structured approach to addressing the issue of handoff errors; one is not necessarily better than the other. Indeed, it is possible for researchers to use both frameworks when designing their study. Ultimately, we provide this example to demonstrate the necessity of selecting conceptual frameworks to clarify the research purpose. 3 , 8   Readers should look for conceptual frameworks in the introduction section and should be wary of their omission, as commonly seen in less well-developed medical education research articles. 14  

Statement of Study Intent

After reviewing the literature, articulating the problem statement, and selecting a conceptual framework to address the research topic, the final step in clarifying the research purpose is the statement of study intent. The statement of study intent is arguably the most important element of framing the study because it makes the research purpose explicit. 2   Consider the following example:

This study aimed to test the hypothesis that the introduction of the BASIC Examination was associated with an accelerated knowledge acquisition during residency training, as measured by increments in annual ITE scores. 15  

This statement of study intent succinctly identifies several key study elements including the population (anesthesiology residents), the intervention/independent variable (introduction of the BASIC Examination), the outcome/dependent variable (knowledge acquisition, as measure by in In-training Examination [ITE] scores), and the hypothesized relationship between the independent and dependent variable (the authors hypothesize a positive correlation between the BASIC examination and the speed of knowledge acquisition). 6 , 14  

The statement of study intent will sometimes manifest as a research objective, rather than hypothesis or question. In such instances there may not be explicit independent and dependent variables, but the study population and research aim should be clearly identified. The following is an example:

“In this report, we present the results of 3 [years] of course data with respect to the practice improvements proposed by participating anesthesiologists and their success in implementing those plans. Specifically, our primary aim is to assess the frequency and type of improvements that were completed and any factors that influence completion.” 16  

The statement of study intent is the logical culmination of the literature review, problem statement, and conceptual framework, and is a transition point between the Introduction and Methods sections of a medical education research report. Nonetheless, a systematic review of experimental research in medical education demonstrated that statements of study intent are absent in the majority of articles. 14   When reading a medical education research article where the statement of study intent is absent, it may be necessary to infer the research aim by gathering information from the Introduction and Methods sections. In these cases, it can be useful to identify the following key elements 6 , 14 , 17   :

Population of interest/type of learner ( e.g. , pain medicine fellow or anesthesiology residents)

Independent/predictor variable ( e.g. , educational intervention or characteristic of the learners)

Dependent/outcome variable ( e.g. , intubation skills or knowledge of anesthetic agents)

Relationship between the variables ( e.g. , “improve” or “mitigate”)

Occasionally, it may be difficult to differentiate the independent study variable from the dependent study variable. 17   For example, consider a study aiming to measure the relationship between burnout and personal debt among anesthesiology residents. Do the researchers believe burnout might lead to high personal debt, or that high personal debt may lead to burnout? This “chicken or egg” conundrum reinforces the importance of the conceptual framework which, if present, should serve as an explanation or rationale for the predicted relationship between study variables.

Research methodology is the “…design or plan that shapes the methods to be used in a study.” 1   Essentially, methodology is the general strategy for answering a research question, whereas methods are the specific steps and techniques that are used to collect data and implement the strategy. Our objective here is to provide an overview of quantitative methodologies ( i.e. , approaches) in medical education research.

The choice of research methodology is made by balancing the approach that best answers the research question against the feasibility of completing the study. There is no perfect methodology because each has its own potential caveats, flaws and/or sources of bias. Before delving into an overview of the methodologies, it is important to highlight common sources of bias in education research. We use the term internal validity to describe the degree to which the findings of a research study represent “the truth,” as opposed to some alternative hypothesis or variables. 18   Table 3   18–20   provides a list of common threats to internal validity in medical education research, along with tactics to mitigate these threats.

Threats to Internal Validity and Strategies to Mitigate Their Effects

Experimental Research

The fundamental tenet of experimental research is the manipulation of an independent or experimental variable to measure its effect on a dependent or outcome variable.

True Experiment

True experimental study designs minimize threats to internal validity by randomizing study subjects to experimental and control groups. Through ensuring that differences between groups are—beyond the intervention/variable of interest—purely due to chance, researchers reduce the internal validity threats related to subject characteristics, time-related maturation, and regression to the mean. 18 , 19  

Quasi-experiment

There are many instances in medical education where randomization may not be feasible or ethical. For instance, researchers wanting to test the effect of a new curriculum among medical students may not be able to randomize learners due to competing curricular obligations and schedules. In these cases, researchers may be forced to assign subjects to experimental and control groups based upon some other criterion beyond randomization, such as different classrooms or different sections of the same course. This process, called quasi-randomization, does not inherently lead to internal validity threats, as long as research investigators are mindful of measuring and controlling for extraneous variables between study groups. 19  

Single-group Methodologies

All experimental study designs compare two or more groups: experimental and control. A common experimental study design in medical education research is the single-group pretest–posttest design, which compares a group of learners before and after the implementation of an intervention. 21   In essence, a single-group pre–post design compares an experimental group ( i.e. , postintervention) to a “no-intervention” control group ( i.e. , preintervention). 19   This study design is problematic for several reasons. Consider the following hypothetical example: A research article reports the effects of a year-long intubation curriculum for first-year anesthesiology residents. All residents participate in monthly, half-day workshops over the course of an academic year. The article reports a positive effect on residents’ skills as demonstrated by a significant improvement in intubation success rates at the end of the year when compared to the beginning.

This study does little to advance the science of learning among anesthesiology residents. While this hypothetical report demonstrates an improvement in residents’ intubation success before versus after the intervention, it does not tell why the workshop worked, how it compares to other educational interventions, or how it fits in to the broader picture of anesthesia training.

Single-group pre–post study designs open themselves to a myriad of threats to internal validity. 20   In our hypothetical example, the improvement in residents’ intubation skills may have been due to other educational experience(s) ( i.e. , implementation threat) and/or improvement in manual dexterity that occurred naturally with time ( i.e. , maturation threat), rather than the airway curriculum. Consequently, single-group pre–post studies should be interpreted with caution. 18  

Repeated testing, before and after the intervention, is one strategy that can be used to reduce the some of the inherent limitations of the single-group study design. Repeated pretesting can mitigate the effect of regression toward the mean, a statistical phenomenon whereby low pretest scores tend to move closer to the mean on subsequent testing (regardless of intervention). 20   Likewise, repeated posttesting at multiple time intervals can provide potentially useful information about the short- and long-term effects of an intervention ( e.g. , the “durability” of the gain in knowledge, skill, or attitude).

Observational Research

Unlike experimental studies, observational research does not involve manipulation of any variables. These studies often involve measuring associations, developing psychometric instruments, or conducting surveys.

Association Research

Association research seeks to identify relationships between two or more variables within a group or groups (correlational research), or similarities/differences between two or more existing groups (causal–comparative research). For example, correlational research might seek to measure the relationship between burnout and educational debt among anesthesiology residents, while causal–comparative research may seek to measure differences in educational debt and/or burnout between anesthesiology and surgery residents. Notably, association research may identify relationships between variables, but does not necessarily support a causal relationship between them.

Psychometric and Survey Research

Psychometric instruments measure a psychologic or cognitive construct such as knowledge, satisfaction, beliefs, and symptoms. Surveys are one type of psychometric instrument, but many other types exist, such as evaluations of direct observation, written examinations, or screening tools. 22   Psychometric instruments are ubiquitous in medical education research and can be used to describe a trait within a study population ( e.g. , rates of depression among medical students) or to measure associations between study variables ( e.g. , association between depression and board scores among medical students).

Psychometric and survey research studies are prone to the internal validity threats listed in table 3 , particularly those relating to mortality, location, and instrumentation. 18   Additionally, readers must ensure that the instrument scores can be trusted to truly represent the construct being measured. For example, suppose you encounter a research article demonstrating a positive association between attending physician teaching effectiveness as measured by a survey of medical students, and the frequency with which the attending physician provides coffee and doughnuts on rounds. Can we be confident that this survey administered to medical students is truly measuring teaching effectiveness? Or is it simply measuring the attending physician’s “likability”? Issues related to measurement and the trustworthiness of data are described in detail in the following section on measurement and the related issues of validity and reliability.

Measurement refers to “the assigning of numbers to individuals in a systematic way as a means of representing properties of the individuals.” 23   Research data can only be trusted insofar as we trust the measurement used to obtain the data. Measurement is of particular importance in medical education research because many of the constructs being measured ( e.g. , knowledge, skill, attitudes) are abstract and subject to measurement error. 24   This section highlights two specific issues related to the trustworthiness of data: the validity and reliability of measurements.

Validity regarding the scores of a measurement instrument “refers to the degree to which evidence and theory support the interpretations of the [instrument’s results] for the proposed use of the [instrument].” 25   In essence, do we believe the results obtained from a measurement really represent what we were trying to measure? Note that validity evidence for the scores of a measurement instrument is separate from the internal validity of a research study. Several frameworks for validity evidence exist. Table 4 2 , 22 , 26   represents the most commonly used framework, developed by Messick, 27   which identifies sources of validity evidence—to support the target construct—from five main categories: content, response process, internal structure, relations to other variables, and consequences.

Sources of Validity Evidence for Measurement Instruments

Reliability

Reliability refers to the consistency of scores for a measurement instrument. 22 , 25 , 28   For an instrument to be reliable, we would anticipate that two individuals rating the same object of measurement in a specific context would provide the same scores. 25   Further, if the scores for an instrument are reliable between raters of the same object of measurement, then we can extrapolate that any difference in scores between two objects represents a true difference across the sample, and is not due to random variation in measurement. 29   Reliability can be demonstrated through a variety of methods such as internal consistency ( e.g. , Cronbach’s alpha), temporal stability ( e.g. , test–retest reliability), interrater agreement ( e.g. , intraclass correlation coefficient), and generalizability theory (generalizability coefficient). 22 , 29  

Example of a Validity and Reliability Argument

This section provides an illustration of validity and reliability in medical education. We use the signaling questions outlined in table 4 to make a validity and reliability argument for the Harvard Assessment of Anesthesia Resident Performance (HARP) instrument. 7   The HARP was developed by Blum et al. to measure the performance of anesthesia trainees that is required to provide safe anesthetic care to patients. According to the authors, the HARP is designed to be used “…as part of a multiscenario, simulation-based assessment” of resident performance. 7  

Content Validity: Does the Instrument’s Content Represent the Construct Being Measured?

To demonstrate content validity, instrument developers should describe the construct being measured and how the instrument was developed, and justify their approach. 25   The HARP is intended to measure resident performance in the critical domains required to provide safe anesthetic care. As such, investigators note that the HARP items were created through a two-step process. First, the instrument’s developers interviewed anesthesiologists with experience in resident education to identify the key traits needed for successful completion of anesthesia residency training. Second, the authors used a modified Delphi process to synthesize the responses into five key behaviors: (1) formulate a clear anesthetic plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize one’s limits. 7 , 30  

Response Process Validity: Are Raters Interpreting the Instrument Items as Intended?

In the case of the HARP, the developers included a scoring rubric with behavioral anchors to ensure that faculty raters could clearly identify how resident performance in each domain should be scored. 7  

Internal Structure Validity: Do Instrument Items Measuring Similar Constructs Yield Homogenous Results? Do Instrument Items Measuring Different Constructs Yield Heterogeneous Results?

Item-correlation for the HARP demonstrated a high degree of correlation between some items ( e.g. , formulating a plan and modifying the plan under changing conditions) and a lower degree of correlation between other items ( e.g. , formulating a plan and identifying performance improvement opportunities). 30   This finding is expected since the items within the HARP are designed to assess separate performance domains, and we would expect residents’ functioning to vary across domains.

Relationship to Other Variables’ Validity: Do Instrument Scores Correlate with Other Measures of Similar or Different Constructs as Expected?

As it applies to the HARP, one would expect that the performance of anesthesia residents will improve over the course of training. Indeed, HARP scores were found to be generally higher among third-year residents compared to first-year residents. 30  

Consequence Validity: Are Instrument Results Being Used as Intended? Are There Unintended or Negative Uses of the Instrument Results?

While investigators did not intentionally seek out consequence validity evidence for the HARP, unanticipated consequences of HARP scores were identified by the authors as follows:

“Data indicated that CA-3s had a lower percentage of worrisome scores (rating 2 or lower) than CA-1s… However, it is concerning that any CA-3s had any worrisome scores…low performance of some CA-3 residents, albeit in the simulated environment, suggests opportunities for training improvement.” 30  

That is, using the HARP to measure the performance of CA-3 anesthesia residents had the unintended consequence of identifying the need for improvement in resident training.

Reliability: Are the Instrument’s Scores Reproducible and Consistent between Raters?

The HARP was applied by two raters for every resident in the study across seven different simulation scenarios. The investigators conducted a generalizability study of HARP scores to estimate the variance in assessment scores that was due to the resident, the rater, and the scenario. They found little variance was due to the rater ( i.e. , scores were consistent between raters), indicating a high level of reliability. 7  

Sampling refers to the selection of research subjects ( i.e. , the sample) from a larger group of eligible individuals ( i.e. , the population). 31   Effective sampling leads to the inclusion of research subjects who represent the larger population of interest. Alternatively, ineffective sampling may lead to the selection of research subjects who are significantly different from the target population. Imagine that researchers want to explore the relationship between burnout and educational debt among pain medicine specialists. The researchers distribute a survey to 1,000 pain medicine specialists (the population), but only 300 individuals complete the survey (the sample). This result is problematic because the characteristics of those individuals who completed the survey and the entire population of pain medicine specialists may be fundamentally different. It is possible that the 300 study subjects may be experiencing more burnout and/or debt, and thus, were more motivated to complete the survey. Alternatively, the 700 nonresponders might have been too busy to respond and even more burned out than the 300 responders, which would suggest that the study findings were even more amplified than actually observed.

When evaluating a medical education research article, it is important to identify the sampling technique the researchers employed, how it might have influenced the results, and whether the results apply to the target population. 24  

Sampling Techniques

Sampling techniques generally fall into two categories: probability- or nonprobability-based. Probability-based sampling ensures that each individual within the target population has an equal opportunity of being selected as a research subject. Most commonly, this is done through random sampling, which should lead to a sample of research subjects that is similar to the target population. If significant differences between sample and population exist, those differences should be due to random chance, rather than systematic bias. The difference between data from a random sample and that from the population is referred to as sampling error. 24  

Nonprobability-based sampling involves selecting research participants such that inclusion of some individuals may be more likely than the inclusion of others. 31   Convenience sampling is one such example and involves selection of research subjects based upon ease or opportuneness. Convenience sampling is common in medical education research, but, as outlined in the example at the beginning of this section, it can lead to sampling bias. 24   When evaluating an article that uses nonprobability-based sampling, it is important to look for participation/response rate. In general, a participation rate of less than 75% should be viewed with skepticism. 21   Additionally, it is important to determine whether characteristics of participants and nonparticipants were reported and if significant differences between the two groups exist.

Interpreting medical education research requires a basic understanding of common ways in which quantitative data are analyzed and displayed. In this section, we highlight two broad topics that are of particular importance when evaluating research articles.

The Nature of the Measurement Variable

Measurement variables in quantitative research generally fall into three categories: nominal, ordinal, or interval. 24   Nominal variables (sometimes called categorical variables) involve data that can be placed into discrete categories without a specific order or structure. Examples include sex (male or female) and professional degree (M.D., D.O., M.B.B.S., etc .) where there is no clear hierarchical order to the categories. Ordinal variables can be ranked according to some criterion, but the spacing between categories may not be equal. Examples of ordinal variables may include measurements of satisfaction (satisfied vs . unsatisfied), agreement (disagree vs . agree), and educational experience (medical student, resident, fellow). As it applies to educational experience, it is noteworthy that even though education can be quantified in years, the spacing between years ( i.e. , educational “growth”) remains unequal. For instance, the difference in performance between second- and third-year medical students is dramatically different than third- and fourth-year medical students. Interval variables can also be ranked according to some criteria, but, unlike ordinal variables, the spacing between variable categories is equal. Examples of interval variables include test scores and salary. However, the conceptual boundaries between these measurement variables are not always clear, as in the case where ordinal scales can be assumed to have the properties of an interval scale, so long as the data’s distribution is not substantially skewed. 32  

Understanding the nature of the measurement variable is important when evaluating how the data are analyzed and reported. Medical education research commonly uses measurement instruments with items that are rated on Likert-type scales, whereby the respondent is asked to assess their level of agreement with a given statement. The response is often translated into a corresponding number ( e.g. , 1 = strongly disagree, 3 = neutral, 5 = strongly agree). It is remarkable that scores from Likert-type scales are sometimes not normally distributed ( i.e. , are skewed toward one end of the scale), indicating that the spacing between scores is unequal and the variable is ordinal in nature. In these cases, it is recommended to report results as frequencies or medians, rather than means and SDs. 33  

Consider an article evaluating medical students’ satisfaction with a new curriculum. Researchers measure satisfaction using a Likert-type scale (1 = very unsatisfied, 2 = unsatisfied, 3 = neutral, 4 = satisfied, 5 = very satisfied). A total of 20 medical students evaluate the curriculum, 10 of whom rate their satisfaction as “satisfied,” and 10 of whom rate it as “very satisfied.” In this case, it does not make much sense to report an average score of 4.5; it makes more sense to report results in terms of frequency ( e.g. , half of the students were “very satisfied” with the curriculum, and half were not).

Effect Size and CIs

In medical education, as in other research disciplines, it is common to report statistically significant results ( i.e. , small P values) in order to increase the likelihood of publication. 34 , 35   However, a significant P value in itself does necessarily represent the educational impact of the study results. A statement like “Intervention x was associated with a significant improvement in learners’ intubation skill compared to education intervention y ( P < 0.05)” tells us that there was a less than 5% chance that the difference in improvement between interventions x and y was due to chance. Yet that does not mean that the study intervention necessarily caused the nonchance results, or indicate whether the between-group difference is educationally significant. Therefore, readers should consider looking beyond the P value to effect size and/or CI when interpreting the study results. 36 , 37  

Effect size is “the magnitude of the difference between two groups,” which helps to quantify the educational significance of the research results. 37   Common measures of effect size include Cohen’s d (standardized difference between two means), risk ratio (compares binary outcomes between two groups), and Pearson’s r correlation (linear relationship between two continuous variables). 37   CIs represent “a range of values around a sample mean or proportion” and are a measure of precision. 31   While effect size and CI give more useful information than simple statistical significance, they are commonly omitted from medical education research articles. 35   In such instances, readers should be wary of overinterpreting a P value in isolation. For further information effect size and CI, we direct readers the work of Sullivan and Feinn 37   and Hulley et al. 31  

In this final section, we identify instruments that can be used to evaluate the quality of quantitative medical education research articles. To this point, we have focused on framing the study and research methodologies and identifying potential pitfalls to consider when appraising a specific article. This is important because how a study is framed and the choice of methodology require some subjective interpretation. Fortunately, there are several instruments available for evaluating medical education research methods and providing a structured approach to the evaluation process.

The Medical Education Research Study Quality Instrument (MERSQI) 21   and the Newcastle Ottawa Scale-Education (NOS-E) 38   are two commonly used instruments, both of which have an extensive body of validity evidence to support the interpretation of their scores. Table 5 21 , 39   provides more detail regarding the MERSQI, which includes evaluation of study design, sampling, data type, validity, data analysis, and outcomes. We have found that applying the MERSQI to manuscripts, articles, and protocols has intrinsic educational value, because this practice of application familiarizes MERSQI users with fundamental principles of medical education research. One aspect of the MERSQI that deserves special mention is the section on evaluating outcomes based on Kirkpatrick’s widely recognized hierarchy of reaction, learning, behavior, and results ( table 5 ; fig .). 40   Validity evidence for the scores of the MERSQI include its operational definitions to improve response process, excellent reliability, and internal consistency, as well as high correlation with other measures of study quality, likelihood of publication, citation rate, and an association between MERSQI score and the likelihood of study funding. 21 , 41   Additionally, consequence validity for the MERSQI scores has been demonstrated by its utility for identifying and disseminating high-quality research in medical education. 42  

Kirkpatrick’s hierarchy of outcomes as applied to education research. Reaction = Level 1, Learning = Level 2, Behavior = Level 3, Results = Level 4. Outcomes become more meaningful, yet more difficult to achieve, when progressing from Level 1 through Level 4. Adapted with permission from Beckman and Cook, 2007. 2  

The Medical Education Research Study Quality Instrument for Evaluating the Quality of Medical Education Research

The NOS-E is a newer tool to evaluate the quality of medication education research. It was developed as a modification of the Newcastle-Ottawa Scale 43   for appraising the quality of nonrandomized studies. The NOS-E includes items focusing on the representativeness of the experimental group, selection and compatibility of the control group, missing data/study retention, and blinding of outcome assessors. 38 , 39   Additional validity evidence for NOS-E scores includes operational definitions to improve response process, excellent reliability and internal consistency, and its correlation with other measures of study quality. 39   Notably, the complete NOS-E, along with its scoring rubric, can found in the article by Cook and Reed. 39  

A recent comparison of the MERSQI and NOS-E found acceptable interrater reliability and good correlation between the two instruments 39   However, noted differences exist between the MERSQI and NOS-E. Specifically, the MERSQI may be applied to a broad range of study designs, including experimental and cross-sectional research. Additionally, the MERSQI addresses issues related to measurement validity and data analysis, and places emphasis on educational outcomes. On the other hand, the NOS-E focuses specifically on experimental study designs, and on issues related to sampling techniques and outcome assessment. 39   Ultimately, the MERSQI and NOS-E are complementary tools that may be used together when evaluating the quality of medical education research.

Conclusions

This article provides an overview of quantitative research in medical education, underscores the main components of education research, and provides a general framework for evaluating research quality. We highlighted the importance of framing a study with respect to purpose, conceptual framework, and statement of study intent. We reviewed the most common research methodologies, along with threats to the validity of a study and its measurement instruments. Finally, we identified two complementary instruments, the MERSQI and NOS-E, for evaluating the quality of a medical education research study.

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Cook DA, Beckman TJ: Current concepts in validity and reliability for psychometric instruments: Theory and application. The American journal of medicine. 2006; 119(2):166. e7–166. e116.

Franenkel JR, Wallen NE, Hyun HH: How to Design and Evaluate Research in Education. 9th edition. New York, McGraw-Hill Education, 2015.

Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB: Designing clinical research. 4th edition. Philadelphia, Lippincott Williams & Wilkins, 2011.

Irby BJ, Brown G, Lara-Alecio R, Jackson S: The Handbook of Educational Theories. Charlotte, NC, Information Age Publishing, Inc., 2015

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Swanwick T: Understanding medical education: Evidence, theory and practice, 2nd edition. Wiley-Blackwell, 2013.

Sullivan GM, Artino Jr AR: Analyzing and interpreting data from Likert-type scales. Journal of graduate medical education. 2013; 5(4):541–2.

Sullivan GM, Feinn R: Using effect size—or why the P value is not enough. Journal of graduate medical education. 2012; 4(3):279–82.

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Support was provided solely from institutional and/or departmental sources.

The authors declare no competing interests.

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Importance of Research in Medical Education

Dipti Magan 1 , *

how to cite: Magan D. Importance of Research in Medical Education. J Med Edu. 2018;17(3):e105647.  https://doi.org/10.22037/jme.v17i3.22269 .

Research in medical education aims to provide a platform for our understanding of learning, teaching, and assessments in medicine. This can be achieved through improving research skills and quality of training in medical education and fosters the continued development of researchers and also to medical faculties, which can be extended to medical students.

Training Research Skills Medical Educators Faculty Development

The body of the article can be found in the PDF file.

References are available in the PDF file.

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The importance of the research experience in undergraduate medical education

The development of strong research skills and the provision of medical care are inextricably linked. That’s why the research experience is stressed during the four years of the undergraduate medical education (UME) program. And it’s why the School has integrated research into the core curriculum, as well as offering several programs for students to become involved throughout their years of study.

“Research makes students better scientists, a core part of being a physician, and better prepares them to lead during residency and in practice,” said Gary Tithecott, associate dean, UME.

Regardless of whether a student plans to become a clinician or follow the path of a clinical scientist, they will be engaged in learning projects to address patient care issues, improve care or to advance an aspect of patient care and how it is delivered in Canada or internationally.

“It’s incumbent upon the UME program to give students the foundational skills and tools, so that they are prepared to meet the immediate needs of their patients, or the future needs of the community,” said Dr. Tithecott.

During their UME, students have an opportunity to engage in research through a number of formal programs funded by the School. These include the Summer Research Opportunities Program, the Summer Research Training Program (SRTP), and the Schulich-UWindsor Opportunities Research Program.

Dani Cadieux, Medicine Class of 2016, has been involved with the SRTP for the past two summers. Her project is medical education-based, with a focus on team communication practices. She has been working with Dr. Mark Goldszmidt, and together they are looking at how junior trainees approach the task of patient follow-up and communication on the internal medicine clinical teaching unit.

The MD/PhD is another program whereby students can pursue their passion for research and combine it with undergraduate medical training. Adrienne Elbert, a Vanier Scholar and multi-award winner, is currently part of the program and has focused her research on the role of epigenetic proteins in embryonic brain development.

There is no shortage of opportunities for students to pursue research, and additional funding and research opportunities are also available directly through departments across the School. Students can also apply for NSERC funding to support projects of interest.

Like many of her peers, Cadieux became involved in research in her first year of medical school and continued on through her second year. While some students continue throughout clerkship, it is more challenging to do so and they often complete their projects during fourth year.

In fourth year, when UME students return to the classroom, they take a course called Integration and Transitions. During the course, students are challenged to ask a question about a patient care topic, they need to show how they would research the issue, and if they were to complete the research, what process they would take.

With the plethora of research projects taking place, the UME program wants to be able to track activity and the impact of the research endeavours. They are now starting to track all projects undertaken at the undergraduate level, even if they are completed during residency.

Unquestionably, the topic of research will be raised during the UME accreditation. “The existence and amount of research activity of our UME students are metrics accreditors will consider and use to compare our School to others,” said Dr. Tithecott.

Most importantly, is the fact that because Schulich Medicine students are exposed to research, they will become more effective, patient-centred physicians once they have graduated.

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Why all doctors should be involved in research

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• Hannah Jacob , academic clinical fellow
• 1 UCL Institute of Child Health, London WC1N 1EH
• hcjacob{at}gmail.com

Neena Modi tells Hannah Jacob about her career in research and why this is a fundamental part of every doctor’s job

Neena Modi is president of the Royal College of Paediatrics and Child Health and professor of neonatal medicine at Imperial College, London. She is a practising clinician and academic lead of a neonatal research programme focusing on nutritional and other perinatal determinants of lifelong metabolic health. After a period as vice president for science and research at the college, she was elected president in April 2015.

How did you become interested in research?

I realised that what I was being taught during my training was wrong, and my very enlightened consultant challenged me to design a trial to back my contention. There were no training posts in neonatal medicine when I started my paediatric training, but there were lots of opportunities to learn and undertake research because the rate of change was so great. That was really exciting.

Which research projects are you most proud of? Which do you think has had the biggest impact?

We did a series of studies to develop methods for measuring body water compartments in extremely preterm babies and to describe the postnatal alterations in fluid balance. We also tested the hypothesis that immediate sodium supplementation in babies with respiratory distress syndrome was harmful. That was a big achievement.

Most recently we have identified possible biological mechanisms that underpin the epidemiological associations between early onset of features of the metabolic syndrome and being born extremely preterm. That is of real interest as we learn more about the long term effects of extremely preterm birth.

How have you coped with the inevitable setbacks of a career in clinical research?

Real life is about being refused things and carrying on anyway, so I have developed resilience. There was no academic training route when I started out, so I have had to forge my own way. People will always tell you that it cannot be done. You have to pursue the things you are passionate about.

Do you have any advice for junior doctors interested in doing research?

Work out what interests you, and then find the person who is going to help you do it. Being approached by an enthusiastic junior doctor is always well received, and once you have found the right senior person they can support you in achieving your goals. Do not lose heart if you don’t get an academic training post as they are not the only way into research. Some of the best research students I have worked with have not come through the standard path.

What would you say to doctors who have no interest in doing research?

I would argue that they may not be thinking broadly enough about what research actually is. Every clinician is responsible for evaluating their own practice, and to do that in a robust and meaningful way you need to use the tools of research. We all need to be able to critically review research done by others. For example, the guidelines used in everyday clinical practice are based on meta-analyses and systematic reviews. So I think all doctors need to be involved in research in some way, and that may be different for different people.

How can undertaking research help doctors in their careers?

It’s not just a help, it’s essential. There are few absolutes in science, and without inquiring minds medicine will stand still. Participation in research enables doctors to evaluate their practice objectively and to be involved in advancing their discipline. You can learn so many skills that make you a better clinician around appraising the evidence and thinking critically about a situation.

What are the benefits and downsides of doing research—both on a personal and professional level?

The benefits come from knowing you are contributing to the science of medicine as well as the art, and are able to question, evaluate, and test different approaches objectively. Everyone has a role in supporting research—many will contribute, and some will be research leaders.

As for downsides, life has ups and downs, and research is no different. You have to not be too disheartened when a grant application gets rejected. When you want to achieve something, you have to keep speaking to the powers that be until you find someone who can be an advocate.

How do you juggle the research, clinical, and leadership aspects of your working life?

It is a balance that is evolving all the time and that provides me with a huge stimulus. Every time I have been presented with an opportunity I have had to evaluate its potential effect on the other components of my work. I always say yes to the things that interest me and follow my muse. We are very privileged as doctors to have such a range of tremendous opportunities available to us.

Do you have a particular philosophy that has guided you in your career?

When life offers you an opportunity, do not turn it down. I believe you must do what grabs your interest, and if you are still doing it years later you know you made the right decision. When you lose the excitement, it is time for a change. The future lies with junior doctors, and you can be a part of shaping it in the way you think is right.

Is there anything you would do differently if you had your career again?

I would have much greater confidence to fight for something I believed in.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I am the academic officer for the Paediatric Educators Special Interest Group of the Royal College of Paediatrics and Child Health.

Medical Education's Active Response to the Opioid Epidemic and Substance Use Disorders

Opioid misuse and substance use disorders (SUDs) have devastated communities across the country, and a collaborative effort is needed to stem the tide. Through their missions of education, research, and clinical care, the nation’s medical schools and teaching hospitals are actively responding to this public health crisis and preparing the next generation of health care professionals to address the epidemic. 

Institutions are actively working with their communities and enhancing content on SUDs and pain management, integrating learning opportunities across the medical education continuum. 

The AAMC supports their work by sharing successful practices, approaches, and responses among educators, clinicians, and future physicians. As part of this effort, and in response to ongoing assessments of the needs of the academic medicine community, the AAMC developed a series of strategic activities to further enhance collaboration and sharing of educational practices, including three opportunities intended for educators. 

Additional information about the AAMC’s strategic efforts, including the results of a national convening, can be found in the following report: “ Responding to the Opioid Epidemic Across the Continuum of Medical Education: Results of a National Action Initiative .”

On this page:

• AAMC Grants/Awards
• AAMC Collaborations
• Curricular Examples
• Regulatory and Policy Updates

AAMC Grants/Awards 

Uc davis research team commissioned for competitive systematic review through aamc/nida partnership .

As part of the AAMC’s ongoing efforts to support its members in advancing educational practices in pain management and SUDs, the association partnered with the National Institute on Drug Abuse (NIDA) to commission a systematic literature review of health care professionals’ bias and stigma related to SUDs and the evidence for mitigation efforts. 

The results of this systematic review have been published in Academic Medicine : “ Stigma Against Patients with Substance Use Disorders Among Health Care Professionals and Trainees and Stigma-Reducing Interventions: A Systematic Review ".

A recording of the January 2024 "Looking Inward: Addressing the Stigma of Addiction" webinar is now available. Sign in to watch the video. 

AAMC Collaborations 

The AAMC collaborates with several organizations to promote and develop curricula and programming. A sample of these collaborations include:

• The Education and Training Work Group of the Action Collaborative developed the 3Cs Framework for Pain and Unhealthy Substance Use: Minimum Core Competencies for Interprofessional Education and Practice to outline the competencies essential for effectively managing pain and addressing issues related to unhealthy substance use in healthcare.
• The AAMC actively collaborates with the Substance Abuse and Mental Health Services Administration (SAMHSA) to engage with medical schools about opioid misuse and SUD education as well as share AAMC resources. 
• The new Medical School Addiction Medicine Curriculum Framework includes resources about model curricula, prevention, and training focused on SUDs.

Curricular Examples 

Curricular innovations and program development .

Over the last five years, several schools and programs have been recognized both for existing exemplary curricula and for the development of new tools and resources towards the advancement of education in addiction and pain management.   

Call for Submissions: Opioids, Addiction, and Pain Education Collection

To foster collaboration between educators and their partners to advance pain management, addiction medicine, and opioid education, MedEdPORTAL is seeking submissions for its Opioids, Addiction, and Pain Education Collection . Examples of appropriate resources include checklists, worksheets, lesson plans, cases, and lecture outlines.

Submit a resource   

Call for Submissions: Integrated Behavioral Health Education 

To equip educators and institutions with curricular innovations to increase collaboration with interprofessional behavioral health teams in undergraduate and graduate medical education, MedEdPORTAL is seeking submissions for its Integrated Behavioral Health Education Collection . This peer-reviewed collection emphasizes equitable care for all patients and communities by providing health professions educators with the tools they need to train the next generation to address stigma related to substance use and mental health conditions.

Submit a resource

If you have any questions, contact [email protected] .

Regulatory and Policy Updates 

Important changes to drug enforcement administration (dea) license requirements affecting all medical educators .

Effective June 27, 2023, all DEA practitioners (except veterinarians) are now required to check a box on their DEA registration application or renewal form indicating that they have satisfied this training requirement. Some practitioners have already satisfied this requirement. Relevant content offered during medical school counts towards this eight-hour requirement. Practitioners who graduated in good standing from a medical (MD or DO granting), dental, physician assistant, or advanced practice nursing school in the United States within five years of June 27, 2023, and successfully completed a comprehensive curriculum that included at least eight hours of training can attest to having met this training requirement without additional action.  

This comprehensive curriculum must include the following:

• Treating and managing patients with opioid or other SUDs, including the appropriate clinical use of all drugs approved by the Food and Drug Administration (FDA) for the treatment of a SUD; or
• Safe pharmacological management of dental pain and screening, brief intervention, and referral for appropriate treatment of patients with or at risk of developing opioid and other SUDs.

Graduates who are unsure if they have met the requirement should reach out to their programs and inquire about the curriculum while they were enrolled. The majority of medical schools include this content in their curriculum.

Medical educators at all U.S. medical schools should:

• Consider reviewing their curricula for the relevant content (listed above) beginning five years ago (June 27, 2018). This does not need to be standalone content and may be integrated throughout the full educational program and experienced in a variety of ways, including simulations, small group discussions, problem-based learning sessions, lectures, clinical rotations, and more.  
• As appropriate, prepare a brief statement to share with graduates (June 27, 2018-2023) indicating that the educational program includes a minimum of eight hours of instruction in these relevant areas for treating and managing patients with opioid or other SUDs, including use of FDA approved treatments.

Graduates who fall outside the five-year window or who graduated from a medical school without the required curricular focus can find accredited continuing medical education activities to complete to meet the DEA requirement. You can sort for relevant activities provided at no charge, offered locally, or provided online.

For more information, see the DEA letter written on March 27, 2023.

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Medical school hotline: importance of research in medical education

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• 1 Department of Tropical Medicine, Medical Microbiology and Pharmacology, University of Hawai'i John A. Burns School of Medicine, USA.
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The role of medical education in the development of the scientific practice of medicine

Lucien cardinal.

a Department of Internal Medicine , Stony Brook University School of Medicine , New York, NY, USA

b John T. Mather Memorial Hospital , Port Jefferson, NY, USA

The authors describe the important role of medical schools and graduate medical education programs (residencies) in relationship to the advances in Medicine witnessed during the twentieth century; diagnosis, prognosis and treatment were revolutionized. This historical essay details the evolution of the education system and the successful struggle to introduce a uniform, science-based curriculum and bedside education. The result was successive generations of soundly educated physicians prepared with a broad knowledge in science, an understanding of laboratory methods and the ability to practice medicine at the bedside. These changes in medical education created a foundation for the advancement of medicine.

During the last 150 years tremendous advances have taken place in the field of medical education. The product of these changes has been the development of physicians who have become progressively scientific in their mode of thought and practice over time. These physicians have been increasingly at the forefront of medicine, incorporating advances in every scientific field into the delivery of healthcare. A systematic and structured educational curriculum was created; this allowed the medical profession to train, through its educational institutions, physicians with the knowledge, skills and attitudes necessary for the scientific practice of medicine. Physicians were graduated with the capacity to study scientific advances, to interpret these advances relative to medicine and to incorporate pertinent elements into their medical practice. The practice of medicine today, contrasted with a century ago, has undergone a metamorphosis that could not have been predicted by the typical American medical graduate of 1900. Medicine has moved from a field based on dogma to one based on fact derived through scientific investigation and clinical observation.

Prior to the twentieth century there existed a plethora of theories explaining health and disease, each one of which conflicted with the other. After 1900 scientific medicine began to be practiced on the wards of several prestigious institutions, yet sectarianism and dogmatism continued to assert itself in the offices of the general practitioner for at least another 30 years, represented by such teachings as homeopathy, naturopathy, eclecticism and abramsism.[ 1 ] Each dogma proposed foundational principles of practice, closed to modification based on observation. There were 22 US homeopathic medical colleges in 1900; Boston University School of Medicine, Hahnemann School of Medicine in Philadelphia (now Drexel), and the New York Homeopathic Medical College (now the New York Medical College) are three examples of schools that were founded on homeopathic principles, later to continue successfully as scientifically based institutions.[ 2 ]

By the dawn of the twentieth century scientific thought and scientific medicine had taken deep root in Germany. However, in the USA the average physician still practiced medicine based largely on the fallacious dogmatic ipse dixits of the particular theory of human health and disease to which the physician subscribed. Most medical school curricula did not include or support the scientific method or attempt to bolster their teachings with the results of experimentation. The unthinking acceptance of dogma was immortalized in William Cowper’s poem, The Task.

Books are oft times talismans and spells , 1 By which the magic art of shrewder wits Holds an unthinking multitude enthrall’d. [ 3 ]

As early as the middle of the nineteenth century, a group of progressive medical leaders began to emerge in the USA. They recognized the need for advancement and advocated for political initiatives. In 1846 the Medical Society of the State of New York called for a national medical organization to be formed, stating that it ‘would be conducive to the elevation of the standard of medical education in the United States.’(p. 4). [ 4 ] This organization was founded as the American Medical Association (AMA) in the following year. Its constitution stated the following as central to its purpose: ‘cultivating and advancing medical knowledge’ and ‘elevating the standard of medical education.’ (p. 2). [ 5 ] Change did not come quickly over the next 50 years, so that in 1902 Dr John Wyeth, president of the AMA, astutely appointed a Committee on Medical Education. The following year, that committee restated under the ‘First Objective of the AMA’ that the organization was ‘formed for the purpose of elevating the standard of medical education.’[4] Sir William Osler, often referred to as the father of Internal Medicine, heralded the changes to come when he stated ‘A new school of practitioners has arisen … It seeks to study, rationally and scientifically …’ the practice of medicine.[ 6 ]

In the early years (1850–1900) medical schools in America, with a few exceptions, stood independent from universities and were proprietary in nature. These two factors tended to isolate the field of medicine from the other sciences. The most advanced medical schools were abroad and were part of established universities. German universities, with centers of learning in Vienna and Berlin, were held in high regard. American physicians frequently traveled to Germany, France and England to advance their post-graduate medical education. On returning home they emulated the practices of institutions they encountered abroad.[ 7 ] Henry P. Bowditch studied in Leipzig and was influenced by the physiological laboratory of Carl Ludwig. He subsequently developed the Institute for Experimental Medicine at Harvard, the first laboratory of its kind in the USA. Similarly, William Henry Welch studied with Ludwig and later went on to become the dean of the Johns Hopkins Medical School and one of the founding physicians of its hospital. He wrote ‘I hope that the Johns Hopkins … will be able to introduce German methods.’[ 8 ] In the early 1900s US physicians were handicapped because the leading medical journals were overwhelmingly in German and not available in the western hemisphere. Several quality US journals were founded in the 1800s and early 1900s to disseminate the findings of medical research. The American Journal of Medical Sciences, a well-respected journal in the USA and Europe, was established by Dr Isaac Hays in 1827. Hays is also credited with the preparation of the Code of Ethics of the AMA. The Journal of the American Medical Association was founded in 1883,[ 9 ] and in 1908 Heinrich Stern founded the Archives of Diagnosis, a leading medical journal of its time.[ 10 ] After attending a conference of the Royal College of Physicians in London in 1913, Stern returned intent on establishing a similar organization. He subsequently founded the American College of Physicians with the intent that it would foster the exchange of scientific information between physicians.[ 11 ]

Standards for admission to an American medical school were lax; a high school diploma was finally mandated in 1905.[ 4 ] New York, through the Department of Education, was one of the few states to require a high school diploma as a prerequisite for medical school admission. Harvard did not require a baccalaureate as a prerequisite until 1901.[ 12 ] Medical schools by and large were two-year programs devoted to bookwork with little exposure to patients at the bedside. The student had little personal contact with the professor, and education was often restricted to lectures heard in an educational amphitheater. Patients were sometimes wheeled in to demonstrate some aspect of medicine to the student.

In 1910, the Carnegie Foundation released a bulletin on medical education in the USA, authored by Abraham Flexner. It became known as the Flexner Report and was regarded as an accurate description of the low standards in medical education at the time. Advocates for the advancement of medical education used it to encourage change. Flexner detailed, over 346 pages, the lack of a systematic and unified approach to medical education, the absence of suitable premedical education and minimal patient-based learning. He also described the factors responsible for the situation and made suggestions for corrective action. Interestingly, Flexner singled out the specialty of Internal Medicine for praise, describing it as the backbone of clinical teaching. He went on to cite another author, quoting ‘… Internal Medicine is regarded as the mother of all other clinical divisions.’[ 13 ]

Over the subsequent 30 years the educational landscape slowly began to succumb to the forces of change. Medical schools defined required premedical coursework, extended the duration of study to four years and incorporated a science-based curriculum.[ 12 , 14 ] They affiliated with universities and teaching hospitals, creating clinical clerkships during the last two years of medical school, allowing students patient-based experiences at the bedside.[ 15 ] Schools that could not accommodate these changes were closed.

Additionally, and importantly, after medical school physicians began to commit themselves to additional specialized educational training by attending hospital-based residencies. Widespread adoption of half-year or single-year internships came quickly, but longer programs of organized training were uncommon. The Johns Hopkins Hospital was established along the lines of the German medical clinics, incorporating full-time professors (‘full-time system’), bedside teaching, clinical observation and laboratory science.[ 16 ] It also incorporated organized multi-year training. It opened its doors on 6 May 1889 and on 15 May admitted its first patient, a case of aortic aneurysm. This was the first patient to receive hospital-based care directly by graduate trainees who were part of an organized multi-year residency program.[ 17 ] Trainees were encouraged to evaluate the impact of treatment and effectiveness of diagnostic tests directly at the bedside. Such proof of action is one aspect of the scientific method. No longer would treatment and diagnosis be based solely on theory. Thus, graduate medical education (GME) was born. Osler, Professor of Medicine at Johns Hopkins, felt that his role in the development of GME was his most important contribution to medicine.[ 18 ] Despite this early development of a modern residency program at Johns Hopkins, medical educators in the USA did not rapidly establish many other multi-year residencies. This is primarily thought to be due to their focused efforts initially to establish rigorous and reputable medical schools, and later the interruptions of World Wars I and II. In lieu of a residency in a medical specialty a physician could attend a condensed course at a so-called post-graduate medical college. These courses were often only weeks in duration. In 1914 there were 17 post-graduate medical schools in the USA, five each in New York and Illinois.[ 19 ] In 1934 the state of Pennsylvania still had only five residency programs of three years or more in length registered with the AMA’s Council on Graduate Medical Education.[ 14 ] Multi-year residency programs preparing physicians for specialization were widely disseminated during the 10 years following the close of World War II.

The advances in medical education and the establishment of graduate medical education stand out as the most important developments in medicine in the last 150 years. They led to the graduation of successive generations of competent physicians, grounded in the scientific practice of medicine. Their openness to discoveries in all fields of science has allowed, with each passing year, for the expansion of medicine to ever-broader horizons.

Disclosure statement

No potential conflict of interest was reported by the authors.

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• Lung Imaging Research
• MRI Hardware Engineering Program
• Neuroimaging Research

Neurovascular Imaging Research

• Oncologic Radiation Therapy Imaging Research
• Quantitative Imaging Analysis Program
• Skeletal Regeneration and Stem Cell Therapy Imaging Research
• Translational Cardiac Imaging Research

Neurovascular disease is one of the major causes of morbidity and mortality worldwide and is the number one cause of adult disability. Medical imaging, including magnetic resonance, computed tomography and positron emission tomography, is increasingly important in the management of numerous neurovascular diseases. Continued innovations in imaging technologies are needed to improve prevention, diagnosis, treatment and therapeutic monitoring. The neurovascular imaging research program is committed to the development of novel imaging techniques and promotion of their clinical applications in various neurovascular conditions and disorders. Our long-term mission is to develop innovative, accurate and reliable imaging solutions to provide precise neurovascular disease management.

• Zhaoyang Fan, PhD
• Qi Yang, MD, PhD

Current research in the neurovascular imaging research program focuses on:

• Carotid artery vessel wall imaging
• Carotid atherosclerotic plaque characterization
• Intracranial artery vessel wall imaging
• Imaging characterization of ischemic stroke patients
• Cerebral venous sinus thrombosis imaging
• Quantitative image analysis for atherosclerotic plaques

Multicontrast Atherosclerosis Characterization for Carotid Atherosclerotic Plaques

Carotid atherosclerotic disease (CAD) is a degenerative disease of the arterial wall caused by the buildup of fatty substances and cholesterol deposits. Disrupted atherosclerotic plaques can lead to transient ischemic attack and cerebral thromboembolic stroke, the leading cause of mortality and morbidity worldwide.

Current management guidelines for CAD are primarily based on the degree of luminal stenosis as determined by medical imaging, with high-grade (greater than 70 percent) stenosis as an indication for surgery or interventional procedures. However, the degree of stenosis may not be an accurate indicator of the severity of disease.

Characterization of so-called vulnerable plaque features, such as the presence of a large lipid-rich necrotic core with an overlying thin/ruptured fibrous cap, intraplaque hemorrhage and calcification can help better identify high-risk lesions. In this regard, magnetic resonance imaging (MRI) has shown unique strengths over other commonly used diagnostic imaging modalities that merely provide information on luminal stenosis.

The multicontrast atherosclerosis characterization (MATCH) technique employs a 3-D spoiled segmented fast low-angle shot readout to acquire data with three different contrast weightings following a nonselective inversion pulse and various inversion-recovery times. This is the first 3-D MRI technique that acquires spatially coregistered multicontrast image sets in a single scan for adequate characterization of carotid plaques (Figure 1).

Whole-Brain Vessel Wall Imaging Using Inversion-Recovery Prepared 3-D Variable-Flip-Angle Turbo Spin-Echo

Cerebrovascular disease, a major cause of morbidity and mortality worldwide, can arise from diverse intracranial vessel wall pathologies such as atherosclerosis, dissection and vasculitis. Methods traditionally used for the diagnosis of the disease are based on lumenography imaging, limited to the detection of luminal abnormalities, thus inadequate for differentiating various wall pathologies.

Recently, there is a growing interest in high-resolution black-blood (BB) MRI, given its capacity to directly assess the intracranial vessel wall and to potentially unravel etiology. Recently, we proposed an inversion-recovery prepared sampling perfection with application-optimized contrast using different flip angle evolutions (IR-SPACE), as a 3-D BB MRI approach to provide remarkable suppression of cerebrospinal fluid signals, enhanced T1 contrast weighting and, most importantly, whole-brain spatial coverage (Figure 2).

Magnetic Resonance Black-Blood Thrombus Imaging

Cerebral venous thrombosis (CVT), including thrombosis of cerebral veins and major dural sinuses, is a relatively uncommon form of stroke that usually affects young individuals. During the past decades, improved diagnosis and treatment have improved the outcome of CVT.

However, there is often a diagnostic delay in patients with CVT, because the confirmation of the diagnosis always relies on the combination of different imaging modalities, such as computed tomography, magnetic resonance (MR), MR venography and conventional X-ray angiography. These methods assess CVT indirectly by imaging venous flow perturbation caused by thrombus. However, given the variation in venous anatomy, it is sometimes difficult to exclude CVT with existing noninvasive imaging studies.

Based on 3-D variable-flip-angle turbo spin-echo, we developed a black-blood MR technique, called black-blood thrombus imaging (BTI), which allows the thrombus to be well isolated from the surrounding tissues. Thus, early detection of CVT is feasible with a high diagnostic accuracy (Figure 3).

Collaborative Research

The neurovascular imaging research program, led by Zhaoyang Fan, PhD, has active collaboration with internal Cedars-Sinai and external research investigators and clinicians. Key collaborators include:

Internal Collaborators

• Michael Alexander, MD
• Bruce Gewertz, MD
• Nestor Gonzalez, MD
• Debiao Li, PhD
• Daniel Luthringer, MD
• Patrick Lyden, MD
• Menahem Marcel Maya, MD
• Frank Moser, MD
• Wouter Schievink, MD
• Konrad Schlick, MD
• Prediman K. Shah, MD
• Shlee Song, MD
• Janet Wei, MD

External Collaborators

• Jiangang Duan, MD, Xuanwu Hospital, Beijing, China
• Xiuhai Guo, MD, Xuanwu Hospital, Beijing, China
• Xunming Ji, MD, Xuanwu Hospital, Beijing, China
• Weijian Jiang, MD, China PLA General Hospital, Beijing
• Eline Kooi, PhD, Maastricht University, the Netherlands
• Fengyuan Man, MD, China PLA General Hospital, Beijing
• Jiayu Sun, MD, West China Hospital of Sichuan University, Chengdu, China
• Wei Yu, MD, Anzhen Hospital, Beijing, China

Have Questions or Need Help?

If you have questions or would like to learn more about the Biomedical Imaging Research Institute at Cedars-Sinai , please call or send us a message.

Biomedical Imaging Research Institute Pacific Theatres Building, Suite 400 116 N. Robertson Blvd. Los Angeles, CA 90048