Where is evidence based medical training?
BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3880 (Published 19 July 2016) Cite this as: BMJ 2016;354:i3880
- Neel Sharma, visiting clinical research fellow
- sharma_neel{at}outlook.com
Abstract
In the first of two articles looking at the evidence underpinning the training and assessment of doctors Neel Sharma considers the new teaching methods introduced in recent years.
In decades past, doctors were trained in overcrowded lecture halls or huddled by the bedside. Learning was through the “see one, do one” method, and often by humiliation. Recently, however, an array of new teaching and learning methods have been introduced, often resulting in confusion as to which should be given the green light.
Case based approaches
One commonly used approach is that of problem based learning (PBL), where students focus on a clinical or a scientific problem.1 This approach encourages self directed learning and teamwork, but there are drawbacks1 such as an overemphasis on the teacher as facilitator and a heavy workload for students.
The concept of team based learning (TBL) also focuses on knowledge application, individually and in teams, but with regular assessments and immediate structured feedback.2
Both PBL and TBL are case based approaches, designed to highlight aspects of basic science, clinical domains, and psychosocial principles. A systematic review of the effectiveness of case based learning found that students enjoy it and feel it enhances their learning. However, the review was inconclusive when it compared case based learning with other methods.34
Interprofessional learning
Training now encourages the use of interprofessional learning, where individuals from different professions learn together.5 Evidence from a systematic review showed that students gained knowledge and skills for collaboration; however there was limited evidence to suggest it influenced attitudes towards others in the service delivery team.5
Technology enhanced learning
Examples of technology enhanced learning include high fidelity simulation and virtual patients.
A systematic review of simulation praised its ability to provide feedback, allow for repetitive practice, tackle a wide range of complex issues, and encourage multiple learning strategies.6 Further evidence, however, concluded that, in comparison with no intervention, simulation was associated with positive effects on knowledge, skills, and behaviours but with moderate effects for patient related outcomes.7 It can also be costly.8
Another concept is the “flipped classroom” where teaching material is delivered to students before class and class time is spent problem solving in teams. It has been praised for its potential to free up class time and allow teachers to teach and provide feedback.9
Further evidence has shown benefits in terms of attendance, learning, and perceived value.10 However, additional studies found no evidence of higher learning gains compared with active non-flipped methods,11 as well as no differences in results, self rated knowledge, or overall course satisfaction.12
Adaptive learning is another hotly debated method. Here, technology allows for content to be tailored to the user, focusing on a candidates’ weaker areas.13 As yet evidence for this approach is lacking.
Competency based medical education
This has become the backbone of teaching and learning. It places emphasis on knowledge, skills, and attitudes,14 but downsides include lengthy lists of required abilities, a lack of mentoring, and an overemphasis on milestones.14 A systematic review concluded that competency based medical education had been adopted by consensus in light of weak empirical evidence.15
There is now a revamped version called entrustable professional activities: units of practice that can be fully entrusted to a trainee once they have demonstrated the necessary competence.16 As yet there is no evidence as to its effectiveness.16
Both concepts encourage the use of portfolios as a means of gathering evidence. Portfolios have been associated with improvements in knowledge and understanding, increased self awareness, and improvements in student tutor relationships.17 However, there have been concerns about the quality of reflections and the time needed for completion.17
Conclusions
It is clear that all educational platforms have both merits and downsides. Unfortunately, institutions are sometimes too quick to incorporate such strategies on the basis of weak evidence. Medical education research is often limited by poor methodological quality, publication bias, inadequate data analysis, and the pre-established interaction between teacher and student, which may lead to reporting bias.
As a trainee I am subject to continuous educational reform. I am not opposed to change but there must be robust evidence for new teaching methods before they are introduced.
Footnotes
Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.