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• Published: 23 March 2022

Student wellness trends and interventions in medical education: a narrative review

• Harrison J. Klein 1 &
• Sarah M. McCarthy 1  

Humanities and Social Sciences Communications volume  9 , Article number:  92 ( 2022 ) Cite this article

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Medical education is a time wrought with personal and professional stressors, posing serious challenges to maintaining student wellness. Extensive research has thus been conducted to identify these stressors and develop practical solutions to alleviate their harmful effects. This narrative review of quantitative and qualitative literature summarizes trends in student wellness and examines interventions deployed by medical schools to ameliorate student distress. Current trends indicate that mental illness, substance use, and burnout are more prevalent in medical students compared to the general population due to excessive academic, personal, and societal stressors. Pass/fail grading systems and longitudinal, collaborative learning approaches with peer support appear to be protective for student wellness. Additionally, maintaining enjoyable hobbies, cultivating social support networks, and developing resiliency decrease distress in medical students on an individual level. Faculty and administrator development is also a necessary component to ensuring student wellness. The COVID-19 pandemic has posed unique challenges to the medical education system and has stimulated unprecedented innovation in educational technology and adaptability. Particularly, the discontinuation of the clinical skill evaluation components for both osteopathic and allopathic students should be a focus of medical student wellness research in the future.

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Defining student wellness.

Defining student wellness has challenged stakeholders throughout the medical education system. The term “wellness” first appeared in literature following World War II, though the concept extends back to Christian ethics of the 19th century that linked physical well-being to moral character (Kirkland, 2014 ). Implicit within these origins of wellness is a responsibility of the individual to contribute to their own well-being. This is reflected in Kirkland’s premise that “each individual can and should strive to achieve a state of optimal functioning” ( 2014 ). Contemporary researchers characterize wellness similarly to the World Health Organization’s (WHO) definition of human health. In the preamble to the WHO’s constitution, health is defined as a “state of complete physical, mental, and social well-being and not merely the absence of disease” (Grad, 2002 ). Wellness can therefore be succinctly defined as self-aware, intentional prevention of distress and promotion of well-being (Kirkland, 2014 ).

Human wellness’s inherent multidimensionality often poses a challenge to quantitative research methods. Most studies thus ultimately measure some combination of indicators for distress and well-being. Addiction, mental disorders, suicidal ideation, and burnout are common indicators of distress assessed through various screening methods (Jackson et al., 2016 ; Moir et al., 2018 ; Dyrbye and Shanafelt, 2016 ). On the contrary, Gallup-Healthways Well-Being Index Composite Score examines well-being across several domains of life, including: life evaluation, emotional health, physical health, healthy behavior, work environment, and basic access. The Well-Being Composite Score thus emphasizes the presence of health rather than absence of disease (Kirkland, 2014 ). Though methodologies and definitions vary across studies and reviews, the fundamental characteristics of wellness appear constant: absence of disease and presence of health. Investigations using this paradigm have identified professional education, particularly medical education, as a time of increased distress and diminished wellness (Dyrbye et al., 2014 ). We have thus undertaken a review of contemporary literature to identify trends in student wellness, as well as the interventions deployed to address such trends. This narrative review outlines the prevalence and contributing factors to mental illness, addiction, and burnout in the medical student population. We then describe several intervention strategies used by medical schools to address student wellness deficits, including: wellness committees, pass-fail (P/F) grading, mindfulness training, curricular alterations, and developing more wellness-aware faculty/administration. In compiling this review, we hope to provide a snapshot of contemporary student wellness that may be used to guide medical schools seeking to improve the student experience during the COVID-19 pandemic and its aftermath.

Mental well-being

As previously mentioned, directly measuring wellness is a challenge in educational research. Therefore, most studies assess wellness of student populations by examining rates of mental illness or distress (Kirkland, 2014 ). Numerous studies have revealed that mental health issues are virtually ubiquitous in the medical education system. Dyrbye and colleagues report that medical school appears to be a peak time for distress in a physician’s training ( 2014 ). Localization of distress to the training process is evidenced by higher rates of depression, fatigue, and suicidal ideation in medical students as compared to age-matched controls from the general population, with these symptoms declining to the same levels as control populations within 5 years after completing post-graduate education (Dyrbye et al., 2014 ). Further, Jackson et al determined that a majority of medical students exhibited either burnout, depressive symptoms, suicidal ideation, alcohol abuse/dependence, or a combination of these factors at the time of survey ( 2016 ). A meta-analysis conducted by Rosenstein and colleagues revealed that 27% of medical students met criteria specifically for depression or depressive symptoms ( 2016 ). This increased prevalence of mental illness is not restricted to medical education. A survey of law students revealed that 17% screened positively for depression, 37% screened positively for anxiety, and 27% screened positively for an eating disorder. These statistics indicate increasing trends of mental illness across graduate education as a whole, rather than medical education alone (Organ et al., 2016 ).

This prolific mental distress can substantially impact medical students’ ability to meet academic demands (Dyrbye et al., 2014 ). As such, substantial research has been conducted investigating factors that contribute to mental illness in an academic setting. Surprisingly, students begin medical school with mental health better than similarly aged peers. However, these roles quickly reverse, with medical student mental health ultimately becoming worse than control populations (Dyrbye and Shanafelt, 2016 ). It seems that medical education may actually select for individuals prone to developing psychological distress (Bergmann et al., 2019 ). Moir et al. report that the majority of medical students are considered Type A individuals, displaying high levels of ambition and competition. Though these qualities facilitate academic success, they also lead to hostility and frustration with challenging situations (Moir et al., 2018 ). Medical students were also found to have high levels of conscientiousness (Moir et al., 2018 ). Conscientiousness is a component of the Big 5 Personality model, which uses the qualities of neuroticism, extraversion, openness, agreeableness, and conscientiousness as the most basic descriptors of an individual’s personality (Shi et al., 2018 ). Conscientiousness is characterized by diligence and careful attention to detail, thus predicting high levels of academic success. However, increased conscientiousness may also exacerbate the likelihood of mental and physical distress due to inordinate demands placed on one’s self (Bergmann et al., 2019 ). Student age was also found to correlate with mental well-being. Younger students were found to approach their studies with dualistic orientations, seeking an explicit, incontrovertible knowledge of medicine. Diagnostic challenges and knowledge gaps ubiquitous in clinical medicine can thus be frustrating to younger students (Lonka et al., 2008 ). It is worth noting that, despite the importance of addressing mental health issues, some authors feel categorizing symptoms of depression and burnout leads to over-medicalization of human suffering and is not useful (Moir et al., 2018 ).

The aforementioned qualities of medical students facilitate development of both maladaptive perfectionism and imposter syndrome, heightening mental wellness concerns in this population (Bubenius and Harendza, 2019 ; Hu et al., 2019 ; Henning et al., 1998 ; Seeliger and Harendza, 2017 ; Thomas and Bigatti, 2020 ). The prevalence of imposter syndrome has been estimated between 22.5–46.6% in medical students, however, the prevalence of perfectionism has proven much more difficult to measure (Thomas and Bigatti, 2020 ). Maladaptive perfectionism is a multifactorial entity encompassing inordinate self-expectations, negative reactions to failure, and a persistent lack of satisfaction in performance (Bubenius and Harendza, 2019 ; Thomas and Bigatti, 2020 ). This emphasis on perfection prevents students from appreciating their vulnerability and thus delays self-recognition of mental distress (Seeliger and Harendza, 2017 ). Not surprisingly, maladaptive perfectionism has thus demonstrated an association with anxiety, depression, bulimia nervosa, anorexia nervosa, and chronic fatigue syndrome (Thomas and Bigatti, 2020 ). The strength of these associations was further demonstrated by Bubenius and Harendza’s use of maladaptive perfectionism as a predictor of depressive symptoms in German medical school applicants ( 2019 ). Imposter syndrome is a phenomenon often associated with maladaptive perfectionism and is characterized by anxiety, lack of self-confidence, depression, and frustration with one’s performance (Clance and Imes, 1978 ). While imposter syndrome bears an uncanny resemblance to perfectionism, the difference lies in imposter syndrome’s characteristic fear of being discovered as undeserving of a place in medical school, regardless of actual accomplishments (Clance and Imes, 1978 ). Imposter syndrome has been associated with a lack of resilience and this, similar to perfectionism, can increase psychological distress (Levant et al., 2020 ). The combined effects of imposter syndrome and maladaptive perfectionism predispose students to mental health issues and thus deserve special attention in studies geared toward well-being interventions. Of note, preliminary work by Chand and colleagues has demonstrated that cognitive behavioral therapy may be especially effective in ameliorating the deleterious effects of maladaptive perfectionism (Chand et al., 2018 ). Treatment for imposter syndrome, however, appears to be a significant gap in wellness literature (Bravata et al., 2020 ).

Deeply intertwined with imposterism and perfectionism is the medical student’s experience of shame. Shame is characterized as a negative emotional response to life events. These life events can take many forms, though personal mistakes within a hostile environment are a common instigator of shame (Bynum et al., 2019 ). Perfectionism and imposter syndrome thus provide a fertile soil of negative self-evaluation in which shame can flourish (Bynum et al., 2020 ). Feelings of shame are further exacerbated by factors within the medical school environment. Mistreatment by colleagues or preceptors, receiving low test scores, underrepresentation within classes, institutional expectations, and social comparison were reported as contributors to shame by medical students in a hermeneutic analysis (Bynum et al., 2021 ). Regardless of origin, shame has been recognized as a “destabilizing emotion,” leading to student isolation, psychological distress, and difficulty with identity formation (Bynum et al., 2021 ). Explorations of shame as a contributor to medical student distress are limited in the current literature. Thus, wellness researchers must dedicate studies to characterizing and preventing this significant, but potentially modifiable, contributor to student distress (Bynum et al., 2019 ).

Medical students’ educational environment can also have a profound impact on mental health, particularly during the early days of training. The transition between college and professional school is marked by anxiety, stress, and financial upheaval. Thus, students may feel more vulnerable than ever as they begin their professional education in a new environment in which they are unaware of available mental health resources, leading to isolation and unnecessary suffering (Organ et al., 2016 ). Even for those aware of these resources, significant stigma still surrounds mental illness in professional education. This is emphasized in Organ et al’s finding that only 50% of law students with mental health issues actually receive professional counseling. Their findings suggest that this reluctance largely stems from fear of professional repercussions if administrators discover a student’s mental health diagnosis (Organ et al., 2016 ). While this study was conducted in law students, Hankir et al found similar trends in both medical students and physicians by examining autobiographical narratives published to combat the stigma against help-seeking behavior (Hankir et al., 2014 ). Hankir and colleagues have elucidated several phenomena that contribute to medical students delaying or even avoiding treatment for mental distress. Self-stigma operates as a powerful deterrent to help-seeking and seems to stem from internalization of society’s expectation that medical students are mentally and physically invincible. This leads to feelings of decreased self-esteem and self-efficacy, as well as fear of stigmatization from the general public (Hankir et al., 2014 ; Fischbein and Bonfine, 2019 ). Rahael Gupta, now a psychiatry resident, brought this stigma to public light as she shared her personal experience with depression during medical school in her short film project entitled “Physicians Connected.” The film, conveyed line-by-line through Gupta’s colleagues at the University of Michigan, highlights the unspoken rule that mental distress is a black mark on a future physician’s career (Gupta, 2018 ). Gupta’s efforts, and those similar, underscore a growing call for public discourse, rather than concealment, of mental well-being within the medical profession. This call is echoed with Robyn Symon’s film “Do No Harm: Exposing the Hippocratic Hoax,” which further explores the toxic culture of medical education that drives physicians and medical students to commit suicide. Both Gupta and Symon highlight the taboo of mental distress within the medical field, which instead prioritizes efficiency and academic success over student and physician well-being. Both films characterize this lack of help-seeking behavior as products of the healthcare system’s toxic structure, rather than individual student distress interacting with a demanding work life (Gupta, 2018 ; Symon 2020 ).

Substance use

In addition to impaired academic performance, mental illness also increases risk for development of substance use disorder in medical students (McLellan, 2017 ). Thus, the pervasiveness of mental illness during medical education warrants careful analysis of substance use patterns in the student population. Alcohol abuse or dependence has already been well documented in the professional education system (Dyrbye and Shanafelt, 2016 ; Organ et al., 2016 ; Jackson et al., 2016 ). Alarmingly, despite 43% of law students reporting a recent occurrence of binge drinking, only 4% had sought professional assistance for alcohol or drug misuse. This trend again highlights significant mental health and addiction stigma throughout the graduate education system (Organ et al., 2016 ). Medical students, and all those in the medical field, may be uniquely affected by this prevalence of substance use. For example, the American Foundation for Suicide Prevention produced a documentary entitled “Struggling in Silence: Physician Depression and Suicide,” which highlights the powerful role that substance use plays in medical student and physician suicide specifically. With a greater knowledge of and access to potentially lethal substances, those in the medical field are at heightened risk for suicide completion, especially with the inhibition-lowering effects of some drugs (AFSP, 2002 ).

Alcohol dependence is of particular concern in medical education due to implications in hindering student career progression and compromised patient safety. Despite this concern, alcohol use is prevalent among medical students. A survey of 855 medical students across 49 schools in the United States revealed that 33.8% of students reported consuming 5 or more drinks in one sitting within the past two weeks, meeting the criteria for binge drinking (Ayala et al., 2017 ). Further, survey responses from 4402 medical students in the U.S. demonstrated that 32.4% met criteria for alcohol abuse/dependence, compared to 15.6% in a control sample of similarly aged but non-medical student counterparts (Jackson et al., 2016 ). The substantial academic stress of a professional education is a clear driving force behind this trend, though several compounding risk factors have been identified. Young males were identified as at an increased risk for alcohol dependence compared to their female colleagues (Jackson et al., 2016 ; Organ et al., 2016 ). Jackson and colleagues further identified that students who were unmarried, diagnosed with a mood disorder, low-income, or burdened with educational debt from professional and undergraduate studies were at increased risk for alcohol dependence ( 2016 ). While ethnicity’s relationship to alcohol use was not explored in medical students, a survey of over 11,000 law students from 15 law schools in 2016 determined that ethnic minorities were more likely to report an increase in drinking whereas Caucasian students were more likely to demonstrate a positive CAGE screening (Organ et al., 2016 ). The CAGE screen is a 4-item questionnaire developed by John Ewing in 1984 to identify drinking problems. The CAGE screen has a 93% sensitivity and 76% specificity for identifying problem drinking whereas alcoholism identification has a sensitivity of 91% and specificity of 77% (Williams, 2014 ). This increased alcohol use in both Caucasian and ethnic minority students demonstrates a need for culturally tailored and inclusive prevention programs.

Though alcohol is the most commonly abused drug amongst medical students, illicit drug use has also been reported at concerning levels. A survey of 36 United States medical schools revealed that approximately one-third of students had used illicit drugs within the past 12 months (Shah et al., 2009 ). Papazisis and colleagues similarly examined illicit drug use in undergraduate medical students in Greece, finding a lifetime substance use rate of ~25% ( 2017 ). Marijuana was the most common illicit drug used in both studies (Shah et al., 2009 ; Papazisis et al., 2017 ). Use of prescription medications without a prescription was also found amongst law students, particularly stimulants such as Ritalin, Adderall, and Concerta (Organ et al., 2016 ). These findings suggest that the competitive culture of graduate education may drive students to engage in recreational drug use, particularly those struggling to meet academic demands or suffering from mental distress.

Student burnout

Burnout was canonically defined by Freudenberger in 1974 as a state of physical and mental exhaustion caused by or related to work activities, often manifesting when heightened professional stress conflicts with personal ideals or expectations (Freudenberger, 1974 ; Rodrigues et al., 2018 ; Baro Vila et al., 2022 ). Though originally a descriptive disorder, burnout is now recognized in the International Classification of Diseases, 10th revision, under code Z73.0 (Lacy and Chan, 2018 ). Burnout is traditionally diagnosed with the Maslach Burnout Inventory, a 22-item questionnaire that characterizes each of the three burnout domains: emotional exhaustion, depersonalization, and personal accomplishment (Dyrbye and Shanafelt, 2016 ). Emotional exhaustion is associated with feelings of being overworked and a subsequent loss of compassion. Depersonalization is characterized by a sense of detachment from colleagues/patients and, when combined with emotional exhaustion, can result in unprofessional behavior. The personal accomplishment domain mainly describes an individual’s feelings of competence and professional satisfaction (Lacy and Chan, 2018 ). In addition to each domain’s unique consequences, burnout domains interact to cause an extinction of motivation when efforts no longer produce desired results (Vidhukumar and Hamza, 2020 ). Approximately 50% of fourth year medical students were found to have burnout when surveyed with the Maslach Burnout Inventory (Dyrbye and Shanafelt, 2016 ). This value holds true internationally according to a survey of medical students conducted in India (Vidhukumar and Hamza, 2020 ). Additionally, burnout increases as training progresses, particularly the depersonalization component (Dyrbye and Shanafelt, 2016 ). Burnout thus increases feelings of callousness towards patients, leading to unprofessional and potentially dangerous conduct. Burnout in medical school also appears to affect specialty choice; burned out individuals were more likely to choose specialties with more controllable lifestyles and higher pay (Dyrbye and Shanafelt, 2016 ). Investigating causes of burnout is thus of utmost importance to understand potential influences on medical student career trajectory and ensuring patient safety.

Identified causes of burnout appear to differ between the years of medical training. Preclinical years are characterized by dissatisfaction with the learning environment and lack of faculty support. Clinical years are characterized by dissatisfaction with the learning environment, clerkship disorganization, and working with cynical or abusive residents and/or attending physicians (Dyrbye and Shanafelt, 2016 ). Reed and colleagues found a positive correlation between the time spent in exams and burnout whereas a negative correlation was observed with increased patient interaction ( 2011 ). Several correlates of burnout outside of medical schools’ learning environments and curricula have also been described, including: female gender, dissatisfaction with career options, non-ethnic minority status, high educational debt, residency competition, expanding knowledge-base, workforce shortage, and stressful events in one’s personal life (Dyrbyre and Shanafelt, 2016 ; Vidhukumar and Hamza, 2020 ). Erosion of social ties during medical education also contributes to the burnout spiral, as socialization is protective against burnout symptoms (Bergmann et al., 2019 ; Busireddy et al., 2017 ). No associations between contact days, time in didactic learning or clinical experiences, and any measure of student well-being and burnout prevalence were found (Reed et al., 2011 ).

Interventions to improve well-being

Medical schools have implemented several interventions to reduce student distress and enhance wellness. Though interventional approaches are varied, researchers have identified salient features common to most successful wellness interventions. For example, Dyrbye and colleagues underline the importance of well-being committees that can liaise between administration, faculty, and students, lessening fear of admonishment for seeking help or acknowledging distress ( 2019 ). Additionally, Moir et al reports that student buy-in is absolutely essential, as disengaged wellness lectures offer little, if any, benefit ( 2016 ). Interventions appear most effective when they are designed to reduce student burdens, rather than adding to the already overwhelming schedule and content of medical school (Busireddy et al., 2017 ). Finally, administrations often pose an obstacle to wellness initiatives, especially those who believe that well-being is of minor importance. This obstacle is reflected by the low prevalence of medical schools with official wellness competencies built into the curriculum (Dyrbye et al., 2019 ). We will now explore some of the specific interventions medical schools have employed to improve student wellness.

Transitioning to a Pass/Fail (P/F) grading scheme is a wellness initiative that has received substantial attention in the United States, especially in light of findings that grade evaluation systems are a larger determinant of student well-being compared to content of educational contact hours (Reed et al., 2011 ; Spring et al., 2011 ). The Mayo Medical School examined the feasibility and effects of P/F grading by introducing the system to first-year medical students in 2006. Rohe and colleagues found that these first-year medical students reported less stress, better overall mood, and greater group cohesion compared to their graded peers. These characteristics persisted into the second year of medical school, even when grading reverted to a traditional 5-level schema (Rohe et al., 2006 ). While critics of P/F grading argue that students will be less motivated to excel academically, evidence suggests that first-year residents from P/F schools performed similarly to residents from graded schools (Rohe et al., 2006 ). Additionally, a P/F system reduces extrinsic motivation and intense competition while increasing cohesion and peer cooperation (Moir et al., 2018 ; Rohe et al., 2006 ). These qualities are essential in the increasingly team-based healthcare landscape. Though transitioning to a P/F system reduced medical student distress during the preclinical years, it is important to note that the transition did not decrease test anxiety for the United States Medical Licensing Exam (USMLE) Step 1 (Williams et al., 2015 ; Rohe et al., 2006 ). Determining test anxiety for USMLE Step 1 will be an active area of research in the face of a new P/F grading for the licensure exam.

Allopathic and osteopathic medical programs are infamous for their academic rigors and intense curricular designs. These curricula are often described as competitive, leisure and socialization-deficient, and requiring exclusive dedication. These characteristics predispose medical students to decreased quality of life (Bergmann et al., 2019 ). As such, altering the curricula of these programs has been investigated as a means to prevent, rather than react to, student distress through a person-in-context perspective (Dyrbye et al., 2005 ; Slavin et al., 2012 ; Slavin et al., 2014 ). It has long been documented that the undergraduate medical curriculum is overflowing with information (D’Eon and Crawford, 2005 ). Rather than identifying salient features for inclusion in courses, medical school faculty often address this surplus of information by cramming unrealistic amounts of information into lectures (D’Eon and Crawford, 2005 ; Dyrbye et al., 2005 ). As mentioned earlier, wellness initiatives are often more effective when they reduce student burdens, rather than adding additional requirements (Busireddy et al., 2017 ). Though this may lead one to believe that shortening curricular hours is an intuitive wellness initiative, this measure only led to workload compression and feelings of being unprepared for clinical practice when used as a unifocal intervention (Dyrbye and Shanafelt 2016 ; Busireddy et al., 2017 ; Dyrbye et al., 2019 ). This continually expanding mass of information thus poses two challenges to wellness initiatives. First, medical students’ schedules are often too consumed by curricular hours to engage in additional wellness programming, especially without an external motivator. Second, the amount of information itself imposes feelings of distress on students, exacerbating the already-stressful nature of medical school and predisposition to mental health issues. Beyond the quantity of curricular hours, delivery and content of those hours is also important to student wellness. Lonka and colleagues found that a collaborative approach to learning increased satisfaction and decreased the perceived workload ( 2008 ). The collaborative environment of problem-based learning may thus offer some improvement to curriculum-induced stress, though current evidence is weak (Camp et al., 1994 ). Incorporating self-care workshops into the curriculum also appears to ameliorate the depersonalization component of burnout (Busireddy et al., 2017 ). In light of these promising results, it follows that the most powerful approach to improving student wellness through curricular restructuring is a multifactorial one. This multifactorial approach is best appreciated in the wellness initiatives within the Vanderbilt University School of Medicine and the Saint Louis University School of Medicine (Drolet and Rodgers, 2010 ; Slavin et al., 2014 ).

The Vanderbilt wellness initiative is composed of three arms: the Advisory College System, the Student Wellness Committee, and Vanderbilt Medical Student LIVE. The Advisory College is composed of both students and faculty that offer personalized advising and mentorship to students within the school. The Student Wellness Committee emphasizes student-led wellness initiatives and serves as an interface with faculty. Lastly, Vanderbilt Medical Student LIVE is an adjunct curriculum that fosters self-care and personal growth amongst the physicians in training (Drolet and Rodgers, 2010 ). The wellness program at the Saint Louis University School of Medicine is structured differently, though shares similar goals. The program entitled Mental Health 3.0 radically, but feasibly and efficiently, altered the structure of the School’s curriculum. Grading was converted to a P/F basis, with only the median exam score and 75 th percentile reported to students. Student contact hours were reduced by 10% during the preclinical curriculum and faculty were advised on how to appropriately identify topics for inclusion in their lectures. Longitudinal electives were instituted following contact hour reduction to encourage student growth and interest identification while forming relationships with fellow students and faculty. These electives were complemented by the formation of five learning communities to further enhance student immersion in areas of interest. Lastly, resilience and mindfulness training was incorporated into the mandatory curriculum while offering an increased number of social events (Slavin et al., 2014 ; Slavin, 2019 ). This wellness initiative was continually expanded and improved to include an early entry and exit to third-year clinical rotations, which minimized stress entering fourth year, and a confidential depression/anxiety tracking system to screen students for worrisome mental health issues (Slavin and Chibnall, 2016 ; Slavin, 2019 ). Comparison between these wellness initiatives reveals that whereas Slavin and colleagues have produced significant declines in student depression, anxiety, and stress with increased group cohesion (Slavin et al., 2014 ; Slavin, 2019 ), the impacts of curricular changes at the Vanderbilt University School of Medicine have not yet been quantified (Drolet and Rodgers, 2010 ). In addition to minimizing student distress, the Mental Health 3.0 program also increased student flourishing (Slavin and Chibnall, 2016 ). The success of Mental Health 3.0 provides strong evidence that diminished medical student well-being is likely a product of multiple factors within the medical learning environment rather than intrinsic student qualities alone (Slavin, 2019 ).

Mindfulness practices have also become increasingly popular as a wellness intervention. Mindfulness is defined as the non-judgmental awareness of one’s own experience with the goal of increasing concentration, insight, and relaxation. Employing mindfulness techniques has been demonstrated to decrease stress and anxiety, though its effects are not as apparent in reducing burnout symptoms (Williams et al., 2015 ). This lack of effect on burnout symptoms may be due to the focus of mindfulness practices, which is on the individual experience rather than improving the structural entities that cause burnout in the first place (Moir et al., 2018 ). Mindfulness practices implemented through peer-support groups in a United States medical school failed to demonstrate improvement in student anxiety, depression, quality of life, or resiliency. Though this may have been due to insufficient peer training, a non-blinded study design, or limited participation, these results lend further support to the need for structural corrections to the medical education system rather than improvement in students’ attitudes or outlooks (Moir et al., 2018 ). This is in contrast to the results obtained when primary care doctors underwent a 52-hour mindfulness training course. Post-course surveys revealed reduced burnout and improved empathy sustained for 3 months post-intervention (Dyrbye and Shanafelt, 2016 ). Comparison of factors contributing to burnout between medical students and practicing clinicians, as well as determining prerequisites for successful implementation of mindfulness programs, may thus be potential areas for research.

Administration and faculty personnel serve as educators and role models for students. Interventions centered on these individuals can thus facilitate a top-down approach to increasing student wellness. A primary concern for German medical students was a lack of coherent information management by faculty with regard to academic expectations, exacerbating the stress of exams and assignments. Solutions offered by students included recording lectures for later viewing and professors providing explicit learning objectives. These students also reported that attendance policies are often too strict and may impede self-care practices, such as utilizing the school counseling system. Proposed solutions were to loosen attendance requirements via a self-reporting absence system (Dederichs et al., 2020 ). Beyond their academic roles, faculty also often serve as mentors to students. The Liaison Committee on Medical Education requires that schools implement a mentoring system for their students, and these mentors are typically medical school faculty. However, Andre et al proposed a vertical mentoring system that complements faculty involvement with senior students in a program entitled “Mentors in Medicine.” This peer-mentoring system was found to be better suited for day-to-day navigation of medical school, while faculty were better suited to offer more long-term career support (Andre et al., 2017 ). Further integration of mentoring to include financial advisors may reduce distress in students with large amounts of educational debt (Dyrbye et al., 2019 ). Faculty commitment to wellness initiatives facilitates the development of communal concern for student wellness, extending beyond the Office of Student Affairs (Slavin et al., 2014 ). Moving forward, faculty and administration will continue to play pivotal roles in student wellness as the medical education system adapts to the technology and challenges of a post-pandemic landscape.

Though a majority of reviewed literature focused on the preclinical years of medical school, important developments have been made in clinical education as well. Dyrbye and Shanafelt found that a longitudinal rotation curriculum, in which students spend several contiguous months at one training site rather than smaller stints at several training sites, facilitates development of meaningful relationships with preceptors, increasing satisfaction and reducing burnout (Dyrbye and Shanafelt, 2016 ). This is congruent with Slavin and Chibnall’s finding that deploying effective wellness initiatives is made difficult by the changing environment of clinical rotations and lack of control over clinician interactions with students (Slavin and Chibnall, 2016 ). Further work by Slavin and Chibnall indicates that negative experiences (e.g., mistreatment) during clinical years are a product of resident burnout, which itself results from toxic healthcare structures and environments (Slavin and Chibnall, 2016 ). For example, residents often experience sleep deprivation, adjustment difficulties, interpersonal conflict, demanding workloads, and a lack of control over their schedule. Interplay between these factors and resident burnout increases likelihood for development of depression and suicidal ideation (Nene and Tadi, 2021 ). These deleterious resident symptoms may then translate to negative interactions with medical students. Improving the medical student experience can thus be facilitated by ameliorating resident burnout. A potential target for resident burnout interventions is resiliency, which has demonstrated a protective effect against burnout (Sheer et al., 2021 ; Nituica et al., 2021 ; Rodrigues et al., 2018 ). For example, implementation of the Gabbe Health and Wellness program, which was structured around an interprofessional Mindfulness in Motion training, significantly increased resiliency in residents at the Ohio State University Wexner Medical Center (Moffatt-Bruce et al., 2019 ). The Mindfulness in Motion training consists of a weekly group meeting with five sequential segments: prompted reflective writing, video presentation on mind/body connectivity, voluntary sharing of reflective responses, video instruction on yoga and mindfulness practices, and a closing meditation (Klatt et al., 2020 ). Though yielding promising results, these methods remain reactive, similar to most medical student wellness initiatives, and do not address the underlying structural causes of burnout within the healthcare system. While current literature lacks specific explorations of the healthcare system’s tendency toward reactive change, as opposed to proactive, this may be an extension of the field’s prioritization of efficiency and academic success over well-being, as mentioned previously (Gupta, 2018 ; Symon, 2020 ). Addressing the correction of such structures is beyond the scope of this review, but deserves serious attention in wellness research. In addition, further explorations of student and resident wellness may involve elucidating the specific motivations within medical culture that keep wellness a low priority within program structuring.

Based on reviewed literature, the following interventions were demonstrated to improve student well-being: transitioning to a P/F grading system, collaborative learning approaches, longitudinal clinical rotation sites, and peer-mentoring programs. General measures for reducing distress include: maintaining hobbies, socialization, positive outlook, avoiding delayed gratification mindsets, learned resiliency, and choosing medicine based off of one’s own interests. Mental Health 3.0 offers an evidence-based approach for successfully implementing these interventions. Measures that did not demonstrate significant improvement include: peer-led mindfulness groups and shortening curricular hours (Vidhukumar and Hamza, 2020 ; Dyrbye and Shanafelt, 2016 ).

The COVID-19 pandemic caused both immediate and long-term changes to the delivery of medical education. At the onset of the pandemic, medical students were removed from clinical rotations to protect against infection. While this ensured their safety, these students were also deprived of peer-engagement due to asynchronous virtual learning. This shift undoubtedly contributed to increased feelings of isolation and risk for burnout (Klasen et al., 2021 ). Despite numerous challenges, the pandemic has also provided opportunities for medical educators to innovate with new technology. For example, senior students on emergency medicine rotations have served as a source of virtual follow-up for emergency department (ED) visits after reviewing medical records. This has allowed students to continue clinical skill development while ensuring safety from infection and proper supervision. Virtual ED follow-ups reflect a growing trend for web-side encounters to serve as a temporary substitute or supplement for clinical rotations (Klasen et al., 2021 ). These digital learning structures were well-received by students, which predicts the persistence of virtual learning in medical school curricula after the COVID-19 pandemic resolves (Dederichs et al., 2020 ). Despite this apparent positive reception, online learning poses challenges to students’ psychological well-being. The asynchronous nature of virtual education modalities lends to feelings of isolation and a lack of motivation during the preclinical years of medical school (Klasen et al., 2021 ). Combined with the already taxing nature of medical education, the stressors of online learning may ultimately exacerbate existing student wellness concerns. Students featured in “Four Years in Blue: The University of Michigan Medical School Documentary” expressed concern for their future clinical training, specifically with regard to availability of personal protective equipment and physician safety. The students also reported feelings of sadness due to a loss of participation in important class milestones, such as a residency match day celebration (Michigan Medicine, 2020 ). Future alterations to the global medical education system in light of the pandemic will thus be an active area of research for years to come. Most notably, the pandemic appears to have served as an impetus for the National Board of Medical Examiners and National Board of Osteopathic Medical Examiners to indefinitely suspend the Step 2-Clinical Skills and Level 2-Performance Evaluation requirement for both allopathic and osteopathic students, respectively (AACOM, 2021 ; USMLE, 2021 ). Student response to this change and its potential effect on student performance should be thoroughly evaluated in future research.

Conclusions and future work

Further reports of wellness programs and interventions aimed at reducing student stress, developing coping strategies, and preventing burnout are needed. As demand for physicians increases and medical school curricula continue to expand, the potential for worsening student wellness increases. COVID-19, stress of licensure exam preparation, and the increasing cost of medical school all add to the brewing pot of pervasive mental illness, substance use, and burnout in the medical student population. Our review of contemporary literature suggests that transitioning to a P/F grading system and implementing longitudinal, collaborative learning approaches with peer support offer solutions to deteriorating medical student wellness. Electives should also be incorporated within the curriculum to further enhance student engagement and excitement for learning (Slavin, 2014 ). Academic faculty should be specifically targeted with instruction on how to reduce extraneous information within courses (Slavin et al., 2014 ; Slavin, 2019 ). Students should also be encouraged to maintain enjoyable hobbies, cultivate social support networks, and maintain a positive outlook to develop resiliency and protect their mental health (Vidhukumar and Hamza, 2020 ; Dyrbyre and Shanafelt, 2016 ). Cognitive behavioral therapy and training in cognitive restructuring techniques should be made available to students in order to address feelings of shame, maladaptive perfectionism, and imposter syndrome (Bynum et al., 2020 ; Chand et al., 2018 ; Slavin et al., 2014 ; Slavin, 2019 ). Confidential depression/anxiety tracking systems to screen students for worrisome mental health issues may also aid in identifying at risk students before mental distress becomes fulminant (Slavin, 2019 ). Faculty and administrators must also strive to improve student wellness from a top-down approach, ensuring that students feel safe to express wellness concerns and seek support when necessary. This may be accomplished through faculty training sessions or development of student liaison committees (Dyrbye et al., 2019 ; Andre et al., 2017 ). Programs at the Saint Louis University School of Medicine and Vanderbilt University School of Medicine offer successful templates for implementation of such programming. With the implementation of any intervention, of course, stringent evaluation guidelines must be employed to ensure optimal improvement to student wellness while avoiding unnecessary burdens to students’ overwhelming schedule.

Data availability

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

American Association of Colleges of Osteopathic Medicine (2021) AACOM, AOA, NBOME support suspension of COMLEX-USA Level 2-PE and continued osteopathic assessment. AACOM. https://www.aacom.org/news-and-events/news-detail/2021/02/17/aacom-aoa-nbome-support-suspension-of-comlex-usa-level-2-pe-and-continued-osteopathic-assessment . Accessed 16 Apr 2021

American Foundation for Suicide Prevention (2002) Struggling in silence: physician depression and suicide. State of the Art, Inc

Andre C, Deerin J, Leykum L (2017) Students helping students: vertical peer mentoring to enhance the medical school experience. BMC Res Note 10(1):176. https://doi.org/10.1186/s13104-017-2498-8

Article   Google Scholar  

Ayala EE, Roseman D, Winseman JS, Mason HRC (2017) Prevalence, perceptions, and consequences of substance use in medical students. Med Educ Online 22(1):1392824. https://doi.org/10.1080/10872981.2017.1392824

Article   PubMed   PubMed Central   Google Scholar  

Baro Vila RC, Burgos LM, Sigal A, Costabel JP, Alves de Lima A (2022) Burnout syndrome in cardiology residents. Impact of the COVID-19 pandemic on burnout syndrome in cardiology residents. Curr Probl Cardiol 47(1):100873. https://doi.org/10.1016/j.cpcardiol.2021.100873

Article   PubMed   Google Scholar  

Bergmann C, Muth T, Loerbroks A (2019) Medical students’ perceptions of stress due to academic studies and its interrelationships with other domains of life: a qualitative study. Med Educ Online 24(1):1603526. https://doi.org/10.1080/10872981.2019.1603526

Bravata DM, Watts SA, Keefer AL, Madhusudhan DK, Taylor KT, Clark DM, Nelson RS, Cokley KO, Hagg HK (2020) Prevalence, predictors, and treatment of impostor syndrome: a systematic review. J Gen Intern Med 35(4):1252–1275. https://doi.org/10.1007/s11606-019-05364-

Busireddy KR, Miller JA, Ellison K, Ren V, Qayyum R, Panda M (2017) Efficacy of interventions to reduce resident physician burnout: a systematic review. J Grad Med Educ 9(3):294–301. https://doi.org/10.4300/JGME-D-16-00372.1

Bußenius L, Harendza S (2019) The relationship between perfectionism and symptoms of depression in medical school applicants. BMC Med Educ 19(1):370. https://doi.org/10.1186/s12909-019-1823-4

Bynum IV WE, Artino AR, Uijtdehaage S, Webb A, Varpio L (2019) Sentinel emotional events: the nature, triggers, and effects of shame experiences in medical residents. Acad Med 94(1):85–93. https://doi.org/10.1097/ACM.0000000000002479

Bynum IV WE, Teunissen WP, Varpio L (2021) In the “Shadow of Shame”: a phenomenological exploration of the nature of shame experiences in medical students. Acad Med 96(11S):S23–S30. https://doi.org/10.1097/ACM.0000000000004261

Bynum IV WE, Uijtdehaage S, Artino Jr AR, Fox JW (2020) The Psychology of shame: a resilience seminar for medical students. MedEdPORTAL 16:11052. https://doi.org/10.15766/mep_2374-8265.11052

Bynum IV WE, Varpio L, Lagoo J, Teunissen PW (2021) ‘I’m unworthy of being in this space’: The origins of shame in medical students. Med Educ 55(2):185–197. https://doi.org/10.1111/medu.14354

Camp DL, Hollingsworth MA, Zaccaro DJ, Cariaga-Lo LD, Richards BF (1994) Does a problem-based learning curriculum affect depression in medical students? Acad Med 69(10 Suppl):S25–7. https://doi.org/10.1097/00001888-199410000-00031 . PMID: 7916817

Article   CAS   PubMed   Google Scholar  

Chand SP, Chibnall JT, Slavin SJ (2018) Cognitive behavioral therapy for maladaptive perfectionism in medical students: a preliminary investigation. Acad Psychiatry 42(1):58–61. https://doi.org/10.1007/s40596-017-0708-2

Clance PR, Imes SA (1978) The imposter phenomenon in high achieving women: dynamics and therapeutic intervention. Psychothe. Theory Res Pract 15:241–247. https://doi.org/10.1037/h0086006

Dederichs M, Weber J, Muth T, Angerer P, Loerbroks A (2020) Students’ perspectives on interventions to reduce stress in medical school: a qualitative study. PLoS ONE 15(10):e0240587. https://doi.org/10.1371/journal.pone.0240587

Article   CAS   PubMed   PubMed Central   Google Scholar  

D’Eon M, Crawford R (2005) The elusive content of the medical-school curriculum: a method to the madness. Med Teach 27(8):699–703. https://doi.org/10.1080/01421590500237598

Drolet BC, Rodgers S (2010) A comprehensive medical student wellness program—design and implementation at Vanderbilt School of Medicine. Acad Med 85:103–110. https://doi.org/10.1097/00001888-199410000-00031

Dyrbye LN, Sciolla AF, Dekhtyar M, Rajasekaran S, Allgood JA, Rea M, Knight AP, Haywood A, Smith S, Stephens MB (2019) Medical school strategies to address student well-being: a national survey. Acad Med 94(6):861–868. https://doi.org/10.1097/ACM.0000000000002611

Dyrbye LN, Shanafelt T (2016) A narrative review on burnout experienced by medical students and residents. Med Educ 50(1):132–149. https://doi.org/10.1111/medu.12927

Dyrbye LN, Thomas MR, Shanafelt TD (2005) Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc 80(12):1613–22. https://doi.org/10.4065/80.12.1613

Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD (2014) Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med 89(3):443–451. https://doi.org/10.1097/ACM.0000000000000134

Fischbein R, Bonfine N (2019) Pharmacy and medical students’ mental health symptoms, experiences, attitudes and help-seeking behaviors. Am J Pharm Educ 83(10):7558. https://doi.org/10.5688/ajpe7558

Freudenberger H (1974) Staff burn-out. J Soc Issues 30(1):159–165. https://doi.org/10.1111/j.1540-4560.1974.tb00706.x

Grad FP (2002) The preamble of the constitution of the World Health Organization. Bull WHO 80(12):981–984

PubMed   Google Scholar  

Gupta R (2018) Physicians connected. https://www.youtube.com/watch?v=Xtfsrqp9XH4&t=191s . Accessed 9 Jan 2022

Hankir AK, Northall A, Zaman R (2014) Stigma and mental health challenges in medical students. BMJ Case Rep. https://doi.org/10.1136/bcr-2014-205226 . PMID: 25183806; PMCID: PMC4158203

Henning K, Ey S, Shaw D (1998) Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Med Educ 32(5):456–64. https://doi.org/10.1046/j.1365-2923.1998.00234.x

Hu KS, Chibnall JT, Slavin SJ (2019) Maladaptive perfectionism, imposterism, and cognitive distortions: threats to the mental health of pre-clinical medical students. Acad Psychiatry 43:381–385. https://doi.org/10.1007/s40596-019-01031-z

Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN (2016) Burnout and alcohol abuse/dependence among U.S. medical students. Acad Med 91(9):1251–1256. https://doi.org/10.1097/ACM.0000000000001138

Kirkland A (2014) What is wellness now? J Health Polit Policy Law 39(5):957–70. https://doi.org/10.1215/03616878-2813647

Klasen JM, Meienberg A, Bogie BJM (2021) Medical student engagement during COVID‐19: lessons learned and areas for improvement. Med Educ 55(1):115–118. https://doi.org/10.1111/medu.14405

Klatt MD, Bawa R, Gabram O, Blake A, Steinberg B, Westrick A, Holliday S (2020) Embracing change: a mindful medical center meets COVID-19. Glob Adv Health Med 9(Dec):2164956120975369. https://doi.org/10.1177/2164956120975369

Lacy BE, Chan JL (2018) Physician burnout: the hidden health care crisis. Clin Gastroenterol Hepatol 16(3):311–317. https://doi.org/10.1016/j.cgh.2017.06.043

Levant B, Villwock JA, Manzardo AM (2020) Imposterism in third-year medical students: an item analysis using the Clance imposter phenomenon scale. Perspect Med Educ 9(2):83–91. https://doi.org/10.1007/s40037-020-00562-8

Lonka K, Sharafi P, Karlgren K, Masiello I, Nieminen J, Birgegard G, Josephson A (2008) MED NORD–A tool for measuring medical students’ well-being and study orientations. Med Teach 30(1):72–79. https://doi.org/10.1080/01421590701769555

McLellan AT (2017) Substance misuse and substance use disorders: why do they matter in healthcare? Trans Am Clin Climatol Assoc 128:112–130

PubMed   PubMed Central   Google Scholar  

Moffatt-Bruce SD, Nguyen MC, Steinberg B, Holliday S, Klatt M (2019) Interventions to Reduce Burnout and Improve Resilience: Impact on a Health System’s Outcomes. Clin Obstet Gynecol 63(3):432–443

Moir F, Henning M, Hassed C, Moyes SA, Elley CR (2016) A peer-support and mindfulness program to improve the mental health of medical students. Teach Learn Med 28(3):293–302. https://doi.org/10.1080/10401334.2016.1153475

Moir F, Yielder J, Sanson J, Chen Y (2018) Depression in medical students: current insights. Adv Med Educ Pract 9:323–333. https://doi.org/10.2147/AMEP.S137384

Nene Y, Tadi P (2021) Resident Burnout In: StatPearls. StatPearls Publishing. Available via: https://www.ncbi.nlm.nih.gov/books/NBK553176/?report=classic . Accessed 19 Feb 2022

Nituica C, Bota OA, Blebea J, Cheng CI, Slotman GJ (2021) Factors influencing resilience and burnout among resident physicians-a National Survey. BMC Med Educ 21(1):514. https://doi.org/10.1186/s12909-021-02950-y

Organ JM, Jaffe DB, Bender KM (2016) Suffering in silence: the survey of law student well-being and the reluctance of law students to seek help for substance use and mental health concerns. J Legal Educ 66(1):116–156

Google Scholar  

Papazisis G, Tsakiridis I, Koulas I, Dagklis T, Kouvelas D (2017) Prevalence of illicit drug use among medical students in Northern Greece and association with smoking and alcohol use. Hippokratia 21(1):13–18

CAS   PubMed   PubMed Central   Google Scholar  

Reed DA, Shanafelt TD, Satele DW, Power DV, Eacker A, Harper W, Moutier C, Durning S, Massie FS, Thomas MR, Sloan JA, Dyrbye LN (2011) Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: a multi-institutional study. Acad Med 86(11):1367–1373. https://doi.org/10.1097/ACM.0b013e3182305d81

Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, Souza T, Gonçalves AK (2018) Burnout syndrome among medical residents: a systematic review and meta-analysis. PLoS ONE 13(11):e0206840. https://doi.org/10.1371/journal.pone.0206840

Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA (2006) The benefits of pass-fail grading on stress, mood, and group cohesion in medical students. Mayo Clin Proc 81(11):1443–1148. https://doi.org/10.4065/81.11.1443

Rosenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen C, Mata DA (2016) Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA 31(21):2214

Seeliger H, Harendza S (2017) Is perfect good?-dimensions of perfectionism in newly admitted medical students. BMC Med Educ 17(1):206. https://doi.org/10.1186/s12909-017-1034-9

Shah AA, Bazargan-Hejazi S, Lindstrom RW, Wolf KE (2009) Prevalence of at-risk drinking among a national sample of medical students. Subst Abus 30(2):141–149. https://doi.org/10.1080/08897070902802067

Sheer AJ, Estores IM, Nickels R, Radhakrishnan N, Goede DL, Mramba LK, Lo MC (2021) Improving burnout and well-being among medicine residents: impact of a grassroots intervention compared to a formal program curriculum. J Educ Health Promot 10:250. https://doi.org/10.4103/jehp.jehp_1378_20

Shi J, Yao Y, Zhan C, Mao Z, Yin F, Zhao X (2018) The relationship between big five personality traits and psychotic experience in a large non-clinical youth sample: the mediating role of emotion regulation. Front Psychiatry 9:648. https://doi.org/10.3389/fpsyt.2018.00648

Slavin S (2019) Reflections on a decade leading a medical student well-being initiative. Acad Med 94(6):771–774. https://doi.org/10.1097/ACM.0000000000002540

Slavin SJ, Chibnall JT (2016) Finding the why, changing the how: improving the mental health of medical students, residents, and physicians. Acad Med 91(9):1194–1196. https://doi.org/10.1097/ACM.0000000000001226

Slavin SJ, Schindler D, Chibnall JT (2014) Mental health 3.0: improving student wellness through curricular changes. Acad Med 89(4):573–577. https://doi.org/10.1097/ACM.0000000000000166 . Medical Student

Slavin SJ, Schindler D, Chibnall JT, Fendell G, Shoss M (2012) PERMA: A model for institutional leadership and culture change. Acad Med 87:1481

Spring L, Robillard D, Gehlbach L, Simas TA (2011) Impact of pass/fail grading on medical students’ well-being and academic outcomes. Med Educ 45(9):867–77. https://doi.org/10.1111/j.1365-2923.2011.03989.x . PMID: 21848714

Symon R (2020) Do no harm: exposing the hippocratic hoax. Symon Productions

Thomas M, Bigatti S (2020) Perfectionism, imposter phenomenon, and mental health in medicine: a literature review. Int J Med Educ 11:201–213. https://doi.org/10.5116/ijme.5f54.c8f8

United States Medical Licensing Examination (2021) Work to relaunch USMLE Step 2 CS discontinued. USMLE. https://www.usmle.org/announcements/?ContentId=309 . Accessed 16 Apr 2021

University of Michigan Medical School (2020) Four Years in Blue: The University of Michigan Medical School Documentary. Michigan Medicine

Vidhukumar K, Hamza M (2020) Prevalence and correlates of burnout among undergraduate medical students-a cross-sectional survey. Indian J Psychol Med 42(2):122–127

Article   CAS   Google Scholar  

Williams D, Tricomi G, Gupta J, Janise A (2015) Efficacy of burnout interventions in the medical education pipeline. Acad Psychiatry 39(1):47–54. https://doi.org/10.1007/s40596-014-0197-5

Williams N (2014) The CAGE questionnaire. Occup Med 64(6):473–474. https://doi.org/10.1093/occmed/kqu058

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This cross-sectional study examines the quality of trauma surgery podcasts for use in medical education.

This cohort study investigates the association of use of text-based secured messaging with telephone use among resident physicians.

• With Great Podcasts Comes Great Responsibility JAMA Network Open Opinion June 20, 2024 Media and Youth Surgery Trauma and Injury Medical Education and Training Full Text | pdf link PDF open access

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Hot Topics: Medical Education Research – Why, How, Why and What

In the next of our hot topic blogs, Dr Fiona Holmes from our BMERG committee talks about what actually defines a ‘Hot topic’ in Medical Education, and the importance of thinking about why and how we find out about what’s new and upcoming in our discipline.

While I was thinking about what to discuss, I realised that what I think is a hot topic might be just lukewarm to other people. We are all driven by different interests, experiences, and priorities.

In the hope of finding relevant and interesting subjects I started by looking into why a topic is hot, how they are identified and why this is important (which links back to why a topic is hot). This led me to what main areas of medical education are currently widely considered to be hot, and we look forward to exploring some of these in more depth in future hot topic blogs.

Why are topics considered ‘hot’?

Hot topics are influenced by various social and cultural contexts and needs, and may be hot because they are:

• Controversial

Within medical education, and by extension pedagogical research in this field, there are a wide range of factors that have been identified to contribute to hotness:

• Advancements in knowledge and technology: It has been estimated that new medical information doubles every 73 days. What and how to teach and the evaluation of learning needs to keep pace with these developments. How to prepare students to deal with such rapid developments and to be life-long learners is also a priority. Advances in technology for teaching and learning as well as the practice of medicine are transforming healthcare and its education. Adapting education to these technological changes will ensure future healthcare professionals are prepared to utilise these tools effectively.
• Patient-centred care: With ever-changing healthcare needs and demographics, education research is needed to address the teaching of emerging health concerns, population health management, and the needs of diverse patient populations. This is twinned with a need for more consideration of patients’ values, preferences, and needs when making healthcare decisions therefore effective education in communication skills, empathy, cultural competence, and shared decision-making.
• Interprofessional collaboration: Effective co-training of different healthcare professionals to foster teamwork skills to prepare students for collaborative healthcare environments.
• Accreditation, regulation, stakeholder input: Accreditation bodies and regulatory agencies may revise guidelines to promote quality, safety, and innovation in medical education, prompting educational institutions to adapt their curricula accordingly. Such changes can drive research in this area. Likewise, public expectations, patient advocacy, and input from stakeholders (e.g., healthcare providers, patients, policymakers) play a role in shaping medical education and its research. These can influence curriculum content, teaching methods, and the overall educational experience.
• Global health and environmental challenges: Global health issues, such as pandemics, emerging infectious diseases, health disparities, as well as environmental contexts highlight the need for a globally competent healthcare workforce. Medical education is addressing these challenges by incorporating global health content, cross-cultural training, and exposure to international healthcare systems.

Then of course there is medical education research itself and the innovation and design that comes with sharing evidence-based practice. This contributes to the evolution of medical education by identifying effective teaching methods, assessment tools, and strategies for continued professional development and aiming to ensure that innovation is beneficial.

How do hot topics get identified and become ‘hot’?

You may initially think that hot topics are simply those that are most prevalent in the current medical education journals, and this may well be true. Most things move in cycles and there are often trends for the types of issues that we see and trends in the solutions implemented. But, when you think about it, how do we find out what is prevalent or ‘trending’ at any given time?

There are number of ways to identify recurring themes, emerging topics and changes in research focus and involve both quantitative and qualitative research methods, and there is some overlap in the methods used. Examples include:

• Literature review:  The systematic search, selection, and evaluation of relevant studies.
• Bibliometric analysis: Analysis of publication and citation patterns over time to provide insight into the volume of research, popular topics, influential authors, and collaborations within the field.
• Content analysis: Systematically categorise and analyse the content of research articles, conference proceedings to identify patterns and trends in research articles, social media discussions and online forums.
• Surveys/questionnaires: Analysis of perceptions and attitudes of educational practices and emerging trends.
• Interviews/focus groups: In-depth exploration of topics and contextual information.

Let’s look at an example:

Ji et al (2018) used social network analysis to identify changing trends in medical education and interpreted their findings to suggest 5 eras of medical education:

They determined that “ during the 53-year period studied, medical education research has been subdivided and has expanded, improved, and changed along with shifts in society’s needs .” By analysing the trends they determined that medical education is forming a sense of the ‘voluntary order’ within the field and establishing legitimacy and originality. ( Ji et al (2018) Research topics and trends in medical education by social network analysis | BMC Medical Education | Full Text (biomedcentral.com) ).

So, why do we need to know about hot topics?

Hot topic research is important to ensure that medical education remains dynamic, responsive, and aligned with the evolving demands of the healthcare field and the needs of the learner. It supports the continuous improvement of medical education, leading to better-prepared healthcare professionals and ultimately improved patient outcomes.

Identifying hot topics helps time-limited researchers and educators stay informed about the latest trends, innovations, and challenges in medical knowledge, education and assessment practices to enhance teaching and learning methods, and to focus efforts on areas that require attention. This can then inform curriculum development and promote evidence-based practices.

Sharing hot topic research also helps to foster collaboration and networking among those with shared interests, leading to the exchange of ideas and development of research networks. As this grows, this helps institutions and funders prioritise and allocate resources by identifying areas of high research interest and impact. This is particularly important in identifying areas of medical education that are under-researched or require further attention.

What is hot right now?

Here are 8 of the hottest topics currently shaping medical education research in 2023:

Technology in education : Virtual (VR) and augmented reality (AR). Digital tools to engage with, filter and disseminate information that are interactive, efficient, and individualised.

Experiential and simulation-based learning : Through VR and AR, standardised patients, manikins, clinical scenarios to allow students to practice complex procedures and decision-making in a safe and controlled environment, improving their skills, confidence and safety.

Interdisciplinary education and team-based learning : Students from various healthcare disciplines learn about, from and with each other collaboratively. Case-based discussions and interprofessional simulations and debriefing, allow students to develop the skills needed to function in teams. It improves patient outcomes and enhances healthcare delivery and professional satisfaction by encouraging mutual respect, understanding, and effective communication.

Diversity, equity, and inclusion : Recruitment and retention of students from diverse backgrounds so that the healthcare profession better represents the patient population. Educating students in culturally appropriate care practices and social determinants of health. Learning environments to promote respect for diverse perspectives and equality of opportunities.

Competency-based education : Teaching and assessing ability to perform specific tasks and skills rather than relying solely on traditional exams to ensure proficiency in essential competencies required for clinical practice.

Biopsychosocial education : Effective teaching and learning to provide a more holistic, ethical and comprehensive approach to patient case.

Wellness and resilience : Self-care, stress management, and mental health support approaches such as mindfulness and peer support networks. Curriculum reform, including flexible scheduling, reducing workload and modifying assessment practices to create a healthier learning environment and promote a culture of empathy and compassion in healthcare.

Data-driven and evidence-based medicine : Education in critical appraisal of biomedical literature, interpret research findings, and apply evidence-based practices in clinical decision-making.

So, I hope it is interesting to consider why we should know the hot topics for research and identify topics that are warming up so that we can strive towards thoroughness in medical education research. We look forward to sharing more hot topics through the BMERG blog.

“Medical education is not just a program for building knowledge and skills in its recipients… it is also an experience which creates attitudes and expectations.” Abraham Flexner

You can also check out Grace’s recent hot topic blog on Reflexive Thematic Analysis here

Do you have a hot topic that you would like to write about for BMERG? Get in touch at [email protected]

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EDITORIAL article

Editorial: trends and challenges of medical education in the changing academic and public health environment of the 21st century.

• 1 The University of the West Indies, Bridgetown, Barbados
• 2 National Defense University of Malaysia, Kuala Lumpur, Malaysia
• 3 Lake Erie College of Osteopathic Medicine, Erie, PA, United States

Editorial on the Research Topic Trends and challenges of medical education in the changing academic and public health environment of the 21st century

Medical education faces challenges in keeping pace with the rapidly changing healthcare needs of populations worldwide ( Majumder et al., 2004 ; Wartman, 2019 ; Gaur et al., 2020 ). Traditional curricula, inadequate funding, and weak quality assurance and accreditation practices contribute to the production of under-equipped graduates ( Torres-Calixto, 2021 ). To effectively address the health problems of the twenty-first century, there is a need for new, more efficient, and effective paradigms in medical and public health education. Health professional institutes must play a central role in developing evidence-based curricula, incorporating new technology, and promoting new programs ( Wartman, 2019 ; Torres-Calixto, 2021 ). Major stakeholders must take a proactive role in bringing about the necessary changes in medical education and public health. Major challenges and changes include the shift toward competency-based education, the increased emphasis on interprofessional education, the use of technology, and addressing social determinants of health in medical education ( Thibault, 2020 ).

In recent years, one of the most significant shifts in medical education has been the transition toward competency-based education (CBE) ( Frank et al., 2010 ; Thibault, 2020 ). CBE focuses on acquiring specific skills and knowledge, as opposed to time-based education, and is viewed as a means of better aligning medical education with the requirements of the healthcare system and patients. Another trend in medical education is the interprofessional education which trains healthcare students from several disciplines to offer patient-centered care through teamwork ( Thibault, 2020 ; van Diggele et al., 2020 ). This strategy is crucial for enhancing healthcare quality and meeting the complicated demands of patients in the current healthcare system. Furthermore, use of technology in medical education—virtual reality, simulation, and online learning are being increasingly used to supplement traditional medical education and provide students with new opportunities for hands-on learning and practice ( Han et al., 2019 ; Thibault, 2020 ).

In addition to these changes, there is a growing emphasis on addressing social determinants of health in medical education ( Lewis et al., 2020 ; Thibault, 2020 ). This includes teaching medical students about the impact of social and economic factors on health outcomes and providing them with the skills to work with communities to address these issues. Despite the changes mentioned above, medical education has largely failed to keep pace with the challenges facing the healthcare system; some of the challenges include the high cost associated with healthcare, concerns of health equity, racial disparities, and shortage of skilled healthcare providers. The current educational strategy fails to deliver value-based care, primarily due to traditional, didactic, fragmented, and static curricula which do not adequately prepare graduates for the complexities of modern healthcare ( Wartman, 2019 ; Gaur et al., 2020 ). To design and implement cost-effective value-based care, the adaptation of updated medical educational curricula is necessary to train the next generation of healthcare providers who can contribute to improve the quality of life of the population. Additionally, global expenditure for medical education and research is inadequate, and this lack of investment in medical education has led to weak quality assurance, accreditation, and educational practices in health professional schools worldwide. To deal with the challenges of the twenty-first century, a needs-based medical education is required that produces a competency-based public health workforce ( Boniol et al., 2022 ). This will require a significant investment in health professional education and a shift from traditional, didactic teaching methods to more innovative and effective ways of instruction ( Torres-Calixto, 2021 ).

In this Research Topic, 35 articles have been published from 17 countries covering medical education and public health-related topics, and a total of 217 authors contributed. Among those, 22 are original articles −17 covered medical education, and the rest highlighted public health aspects. The medical education articles can be organized under two major themes: (i) the use of technology in health professional education, and (ii) health professional education and training by traditional methods.

Public health and medical education are closely linked, as both seek to improve the health and wellbeing of individuals and communities ( Rao et al., 2020 ). Medical education equips healthcare practitioners with the competencies necessary to successfully diagnose, treat, and prevent diseases, whereas public health focuses on recognizing and addressing the broader health issues and needs of the population. Together, they aim to advance health equity and enhance health outcomes generally. To assist future physicians in understanding how to consider population health and address health inequities, medical training can also place a significant emphasis on public health education ( Thibault, 2020 ).

Six articles investigated the impact of technology on health professional education. Technology is used for assessment, such as electronic testing and tracking student progress and to enhance the educational experience of students and faculty. Technology has been widely used during the COVID-19 pandemic for distance learning and online courses, making education more accessible to students specially in remote areas ( Gaur et al., 2020 ). Singh et al. examined the use of smartphones and related medical education apps by medical students which improved their educational experiences. Luo et al. found that high-quality YouTube videos related to atrial fibrillation submitted by medical personnel were not popular and did not receive much attention. Gilavand showed a positive impact of M-Learning among faculty members. Bisdas et al. explored the perception of artificial intelligence among medical and dental students in 63 countries. Peng et al. evaluated the teaching effect of simulation-based education in clinical medical students and found that first aid simulation-based education effectively improved the students' proficiency in managing real emergencies. Coronel-Ocampos et al. identified that the majority of the students experienced computer vision syndrome during the COVID-19 pandemic. The pandemic has presented a unique set of challenges to health professional education. These challenges should act as catalysts for reimagining how we deliver health professional education and training in the future ( Gaur et al., 2020 ; Singh et al., 2020 ; Majumder et al., 2021 ; Lashley et al., 2022 ). In the following section, a number of authors ( Choi et al. ; Pedro et al. ; Yu et al. ; Xin et al. ) highlighted their experiences in relation to the implementation of modified learning strategy during the pandemic.

Eleven articles were published under the second theme—health profession education and training. Health professional education and training are essential for ensuring that healthcare professionals have the knowledge, skills, and attitudes necessary to provide safe and effective care to patients. Healthcare workers with the proper education and training are better equipped to make correct diagnoses, administer appropriate treatments, and communicate effectively with patients, relatives, and other members of the healthcare team ( Boniol et al., 2022 ). Education and training also ensure that healthcare personnel can keep up with breakthroughs in medical knowledge and the development of novel treatments. Given the rapid rate of change in healthcare and the exponential growth of scientific information, this is particularly crucial. Furthermore, the global shortage of healthcare professionals and the rising demand for healthcare services demonstrate the significance of competency-based health professional education and training. Countries can meet the needs of their populations and enhance health outcomes when their workforces are properly educated and well-trained. In addition, as concerns about patient safety increase, the quality of care and patient outcomes are strongly correlated with the education and training of healthcare personnel. Thus, effective education and training of healthcare personnel are necessary for sustaining high standards of care and enhancing patient outcomes ( World Health Organization, 2016 ). Tang et al. observed the improvement in the quality of training of resident physicians in China using “Plan-Do-Check-Action” Plan. An et al. assessed the training needs of continuing medical education of general practitioners in Tibet and recommended adopting “demand-oriented curriculum” and “staged training plans” to enhance the core professional capability of general practitioners. Awang et al. adopted a Clinical Practice Guideline in a Nurse-Led Ventilator-Weaning program and noticed the change in the perception of practice and professionalism among nurses in Malaysia. Noorali et al. reported the success of a nationwide virtual research education program for Medical Students in Pakistan. Choi et al. discussed the experiences of “chaos and change” in laboratories and clinical teaching in nursing education in South Korea during the COVID-19 pandemic. Pedro et al. conducted a comparative analysis of undergraduate psychiatry and mental health curricula and Yu et al. examined the impact of the COVID-19 pandemic on the mental health and academic performance of postgraduate medical students. Xin et al. observed the impact of “Real Workload-Situated Training” in COVID-19 Prevention and control targeted for general practice residents, and Chawłowska et al. examined the potential of student volunteering in undergraduate health professional education. You et al. conducted a bibliometric analysis to explore emerging high-intensity interval training in health promotion, and Leadbeater et al. used a virtual approach to promote inter-professional learning between biomedical science and medicine to benefit patient care. Finally, Asakawa et al. conducted a qualitative study among resident physicians to assess coping and learning through self-disclosure after medical errors.

Three original studies covered public health issues focusing on exercise and physical fitness, healthcare financing, and the evolution of the healthcare system. Lv et al. reported how peri-operative exercise could improve physical fitness and health status to reduce the risk of peri-operative morbidity and mortality. Chinese people's peri-operative exercise intention level is low, and multiple factors, including biological and social environments, influence it. The authors recommended that the intention for peri-operative exercise should consider gender, the intensity of daily exercise, hospital grade, positive attitude toward daily exercise, preoperative anxiety, positive attitude toward peri-operative exercise, and social support.

The finance of health professional education serves as the basis of effective and sustainable health systems, yet relevant empirical research is scarce due to the lack of financial data. Gao et al. aimed to bridge the gap by presenting the financing of health professional institutions in China and exploring how the stratification of institutions affected their funding disparities. Using the Chinese Ministry of Education data, the authors reported that the number of health professional institutions has kept growing over the past two decades, with funding per institution and funding per student increasing steadily. The funding disparities between tiers of health professional institutions gradually became more accentuated, with the top-tier institutions taking up the largest share. Unified quality assurance of medical personnel training is a practical pathway to achieve stable and sustainable development in health professional education.

Marchenko and Bykov reported the importance of developing research in techno-scientific biomedical communication during the COVID-19 pandemic. The authors analyzed the evolution of the healthcare system in Russia with an emphasis on public communication and found that the promotion of high-tech medicine is related to the proportionate output of governmental institutions. There is also a concern over import substitution resulting from the current geopolitical crisis.

Apart from these, two brief research reports highlighted the gender differences and influencing factors in specialty choices ( Yin et al. ) and health communication and inter-professional care ( Pati et al. ). Three articles were published under the category of Curriculum, Instruction, and Pedagogy, which focused on tailored teaching of cell biology ( Schoenmaker et al. ), inter-professional education ( Liller et al. ), and nursing curriculum ( Alias et al. ).

Zhao et al. conducted a systematic review to examine the knowledge about, attitude toward, and practice of complementary and alternative medicine of nursing students. Four narrative reviews discussed the lifestyle interventions and oncology education ( Jia et al. ), pathology workforce challenges during the pandemic ( Hassell and Afzal ), gynecologic oncology sub-specialty training ( Erem et al. ), and antimicrobial resistance ( Dhingra et al. ). The widespread use of antimicrobial drugs to treat COVID-19 patients and the likely emergence of antibiotic-resistant microorganisms is a global health concern ( Razzaque, 2021a ). Integrating antimicrobial stewardship teaching in medical curricula to train future prescribers is essential to avoid such disastrous consequences ( Majumder et al., 2020 ; Razzaque, 2021b ). Dhingra et al. and Razzaque highlighted a global health threat posed by antimicrobial resistance. Razzaque wrote a commentary highlighting the importance of coordinated and collaborative efforts of national and international governmental and private organizations to counter the emerging threat. A minireview examined the trends and innovations of simulation training in medical education ( Herrera-Aliaga and Estrada ). Under the Perspective category, Yokomichi et al. discussed cross-disciplinary collaboration and innovation in epidemiology in Japan. Finally, Amin et al. addressed the challenges in humanistic communication during COVID-19 through medical education.

In conclusion, despite the changes in medical education, it has largely failed to keep pace with the challenges facing the healthcare system in the twenty-first century. This problem has been compounded by the traditional didactic and fragmented teaching approach to medical education, as well as the absence of funding for health professional education and research. To address the issues, medical education must take a more interdisciplinary and comprehensive approach focusing on population health, multidisciplinary teamwork, and community-based education and training. In addition, it is crucial that medical education be centered on the priority health needs and specific concerns of the community ( Nzabonimana et al., 2019 ). It is also essential to invest in training diversified public health personnel in order to address the various health issues facing communities by including epidemiology, health promotion, and health policy in the training curricula. To effectively handle the healthcare concerns of the twenty-first century, medical education and public health training must adopt a more collaborative and community-based approach.

Author contributions

MM wrote the first draft. MM, MH, and MR revised and approved the final submitted version. All authors contributed to the article and approved the submitted version.

Acknowledgments

The authors wish to thank Md. Sayed Shehran Azim for providing useful suggestions.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Boniol, M., Kunjumen, T., Nair, T. S., Siyam, A., Campbell, J., Diallo, K., et al. (2022). The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage? BMJ Glob Health . 7, e009316. doi: 10.1136/bmjgh-2022-009316

PubMed Abstract | CrossRef Full Text | Google Scholar

Frank, J. R., Snell, L. S., Cate, O. T., Holmboe, E. S., Carraccio, C., Swing, S. R., et al. (2010). Competency-based medical education: theory to practice. Med. Teach . 32, 638–645. doi: 10.3109/0142159x.2010.501190

Gaur, U., Majumder, M. A. A., Sa, B., Sarkar, S., Williams, A., Singh, K., et al. (2020). Challenges and opportunities of preclinical medical education: COVID-19 crisis and beyond. SN Compr. Clin. Med . 2, 1992–1997. doi: 10.1007/s42399-020-00528-1

Han, E.-R., Yeo, S., Kim, M.-J., Lee, Y.-H., Park, K. H., and Roh, H. (2019). Medical education trends for future physicians in the era of advanced technology and artificial intelligence: an integrative review. BMC Med. Educ . 19, 460. doi: 10.1186/s12909-019-1891-5

Lashley, P. M., Sobers, N. P., Campbell, M. H., Emmanuel, M. K., Greaves, N., Hilaire, M. G., et al. (2022). Student satisfaction and self-efficacy in a novel online clinical clerkship curriculum delivered during the COVID-19 pandemic. Adv. Med. Educ. Pract . 13, 1029–1038. doi: 10.2147/amep.s374133

Lewis, J. H., Lage, O. G., Grant, B. K., Rajasekaran, S. K., Gemeda, M., Like, R. C., et al. (2020). Addressing the social determinants of health in undergraduate medical education curricula: a survey report. Adv. Med. Educ. Pract . 11, 369–377. doi: 10.2147/amep.s243827

Majumder, A. A., D'Souza, U., and Rahman, S. (2004). Trends in medical education: challenges and directions for need-based reforms of medical training in South-East Asia. Indian J. Med. Sci . 58, 369–380.

PubMed Abstract | Google Scholar

Majumder, M. A. A., Gaur, U., Singh, K., Kandamaran, L., Gupta, S., Haque, M., et al. (2021). Impact of COVID-19 pandemic on radiology education, training, and practice: a narrative review. World J. Radiol. 13, 354–370. doi: 10.4329/wjr.v13.i11.354

Majumder, M. A. A., Singh, K., Hilaire, M. G., Rahman, S., Sa, B., Haque, M., et al. (2020). Tackling antimicrobial resistance by promoting antimicrobial stewardship in medical and allied health professional curricula. Expert Rev. Anti Infect. Ther . 18, 1245–1258. doi: 10.1080/14787210.2020.1796638

Nzabonimana, E., Isyagi, M. M., Njunwa, K. J., Hackley, D. M., and Razzaque, M. S. (2019). Use of an online medical database for clinical decision-making processes: assessment of knowledge, attitude, and practice of oral health care providers. Adv. Med. Educ. Pract . 10, 461–467. doi: 10.2147/amep.s146451

Rao, R., Hawkins, M., Ulrich, T., Gatlin, G., Mabry, G., Mishra, C., et al. (2020). The evolving role of public health in medical education. Front. Public Health 8, 251. doi: 10.3389/fpubh.2020.00251

Razzaque, M. S. (2021a). Exacerbation of antimicrobial resistance: another casualty of the COVID-19 pandemic? Expert Rev. Anti Infect. Ther . 19, 967–971. doi: 10.1080/14787210.2021.1865802

Razzaque, M. S. (2021b). Implementation of antimicrobial stewardship to reduce antimicrobial drug resistance. Expert Rev. Anti Infect. Ther . 19, 559–562. doi: 10.1080/14787210.2021.1840977

Singh, K., Gaur, U., Hall, K., Mascoll, K., Cohall, D., Majumder, M., et al. (2020). Teaching anatomy and dissection in an era of social distancing and remote learning. Adv. Hum. Biol. 10, 90–94. doi: 10.4103/AIHB.AIHB_87_20

CrossRef Full Text | Google Scholar

Thibault, G. E. (2020). The future of health professions education: emerging trends in the United States. FASEB Bioadv. 2, 685–694. doi: 10.1096/fba.2020-00061

Torres-Calixto, M. G. (2021). Trends and challenges of medical education. Rev. Facult. Med . 69, e301. doi: 10.15446/revfacmed.v69n3.84330

van Diggele, C., Roberts, C., Burgess, A., and Mellis, C. (2020). Interprofessional education: tips for design and implementation. BMC Med. Educ . 20, 455. doi: 10.1186/s12909-020-02286-z

Wartman, S. A. (2019). The empirical challenge of 21st-century medical education. Acad. Med . 94, 1412–1415. doi: 10.1097/ACM.0000000000002866

World Health Organization (2016). Education and Training: Technical Series on Safer Primary Care .

Keywords: public health, medical education, learning objectives, learning outcome, global health

Citation: Majumder MAA, Haque M and Razzaque MS (2023) Editorial: Trends and challenges of medical education in the changing academic and public health environment of the 21st century. Front. Commun. 8:1153764. doi: 10.3389/fcomm.2023.1153764

Received: 30 January 2023; Accepted: 06 March 2023; Published: 24 March 2023.

Edited and reviewed by: Rukhsana Ahmed , University at Albany, United States

Copyright © 2023 Majumder, Haque and Razzaque. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Md. Anwarul Azim Majumder, azim.majumder@cavehill.uwi.edu ; Mainul Haque, mainul@upnm.edu.my ; Mohammed S. Razzaque, mrazzaque@lecom.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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• Geoff Norman ( norman{at}mcmaster.ca ) , professor
• Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada L8N 3Z5
• Correspondence to: G Norman

The specialty of research in medical education began just over three decades ago with a small group of clinicians and educational researchers at the medical school in Buffalo, New York. Since that time it has expanded worldwide. This paper is a personal reflection on how this research has informed our understanding of learning, teaching, and assessment in medicine.

Summary points

Research in medical education has contributed substantially to understanding the learning process

The educational community is becoming aware of the importance of evidence in educational decision making

Areas of major development include basic research on the nature of medical expertise, problem based learning, performance assessment, and continuing education and assessment of practising physicians

Measuring progress

In medicine, indicators of scientific progress might be measured by objective indicators such as death from cardiovascular disease. In education such “hard” evidence may be lacking for several reasons. Firstly, paradoxically, real differences in educational strategies may not be reflected in outcomes, such as licensing examination performance, simply because students are highly motivated and are not blinded to the intervention, so will compensate for any defects in the curriculum. 1 – 5 Secondly, a curriculum is not like a drug, which can be given at standard doses, but instead contains many components, delivered with variable quality by different teachers. Finally, the time between learning and important outcomes may be so long that the effects of the curriculum are obscured—although not always. 6

Use of evidence in educational decision making

Perhaps the most important evidence of progress in the discipline is that we are now more likely than before to demand evidence to guide educational decision making. Before 1970 important educational advances were largely adopted by persuasion and politics; since that time changes are more likely to be initiated or accompanied by evidence. Although this may sound circular, it represents tangible recognition of the contributions that research can make to the practice of education.

Specific areas of progress

Beyond this cultural change, the following broad domains have seen real progress: basic research in the acquisition of expertise, problem based learning, advances in assessment methods, and continuing education, recertification, and relicensure.

Basic research in the acquisition of expertise

In the early 1970s basic research into the nature of clinical reasoning pursued the hypothesis that expert clinicians were distinguished by the possession of general “clinical problem solving” skills. This was wrong; what emerged was that expertise lay predominantly in the knowledge, both formal and experiential, that the expert brought to the problem. 7 8

This finding resulted in a new direction of inquiry, and a new generation of researchers attempted to uncover the ways that expert clinicians organise medical knowledge in their minds, using research strategies derived from cognitive psychology. 9 10 Although the fruits of these labours are not yet ripe, the research has moved from purely descriptive research to experimental studies directed at a better understanding of the process and theory based interventions that promise to improve the effectiveness of instruction. 11

Problem based learning

Problem based learning developed at McMaster University in the late 1960s, driven by a desire to construct a medical school that was more humane than one that used the traditional, lecture based approach. Since that time an extensive body of evidence has emerged about its effectiveness. 2 – 5 12 If the evaluation is restricted to the central educational outcomes such as performance on licensing examinations, few differences are found. 2 3 This should not be a surprise—most students will do whatever is necessary to compensate for any perceived weakness in a curriculum. 13 However, in terms of the original goal of creating a humane learning environment, problem based learning is an unqualified success. 3 4

Advances in assessment methods

Arguably the most dramatic advances have occurred in approaches to assessment. Thirty years ago assessment was dominated by written tests—essays in Europe and multiple choice questions in North America. When performance assessment did occur, as in specialty certification, the traditional viva dominated. Moreover, there was a paucity of evidence about the strengths and weaknesses of various approaches.

(Credit: TOPHAM PICTUREPOINT)

Medical education, 1960s-style

That has all changed. In the 1970s there was a proliferation of simulation approaches to assessing higher skills like problem solving. These developments were accompanied by careful research, largely stimulated by the licensing and certification bodies in the United States. Content specificity has been a major finding of this research—the correlation of the various measures of skills across problems was typically in the range of 0.1 to 0.3, 14 so many samples of behaviour were necessary to obtain stable, thus reliable, measurement. It is a direct consequence of content specificity that the objective structured clinical examination, 15 with its multiple samples of performance, has come to dominate performance assessment and has led to an extensive literature regarding the impact of various elements such as ratings of simulated patients versus physician observers.

Additional educational resources

Useful websites.

Queen's University, Ontario, Canada ( http://meds.queensu.ca/medicine/pbl/pblhome.htm )—problem based learning home page from Queen's University's School of Medicine

Clerkship Directors in Internal Medicine Task Force Subgroup Report ( lhttp://www.im.org/cdim/5educate/eval/clinical.html )—evaluation of clinical competence

National Board of Medical Examiners ( http://www.nbme.org/about/itemwriting.asp )—constructing written test questions for the basic and clinical sciences

Useful publications

Norman GR, Schmidt HG. The psychological basis of problem-based learning: a review of evidence. Acad Med 1992;67:557-65.

Norman GR, van der Vleuten CPM, Newble DI. International Handbook of Research in Medical Education . Dordrecht: Kluwer, 2002.

Swanson DB, Norman GR, Linn RL. Performance based assessment: lessons from the health professions. Educ Res 1995;24:5-11.

This research has led to major advances in performance assessment—for example, the Medical Council of Canada now administers a performance examination to 1800 licensure candidates each year. 16 Changes in assessment methods at the school level have, however, been much slower in coming. 17

Research foci and major findings

Basic research on reasoning.

Generic reasoning skills are non-existent

Knowledge (formal and experiential) is a critical determinant of reasoning

Self directed learning does not result in lower knowledge

Students and teachers are happier and more satisfied

Performance assessment

Multiple sampling strategies are crucial to reliable, valid assessment

Performance can be assessed as well as knowledge

Continuing education

Improved reliable methods for performance assessment in practice

Systematic approaches to relicensure

Continuing education, recertification, and relicensure

While continuing education of health professionals remains dominated by the “day in medicine,” when physicians assemble and hear a full day of lectures on a particular topic from academic specialists, a substantial body of evidence has emerged pointing to the deficiencies of this approach, and, more importantly, identifying alternative methods that are effective. 18

These changes have paralleled dramatic changes in the assessment of practising physicians. Society is challenging the presumed right of independent practice conferred on the physician at the time of licensure, and the medical education community has responded by devising and implementing several defensible strategies for reassessment. One highly innovative approach is the use of unidentified standardised patients who enter physicians' practices undetected. 19 20 Another is the serious attempt to identify and deal with incompetent physicians through formal performance assessment both in Canada and in the United Kingdom. 21 22

The outcome of medical education

Research in medical education is no longer in its infancy (see box). While it remains multifocal, with nearly as many research methods as researchers, there is a growing body of knowledge about the process and outcome of medical education.

In my view there has been insufficient attention to the interface between our understanding of clinical expertise and the application of this knowledge to improve instruction and assessment. Studies at the curriculum level of complex “treatments” like problem based learning are unlikely to reveal a deeper understanding of the interface between instruction and learning. Real improvement in education, just like real improvements in medical treatments, will only result when we combine better the understanding of basic science with the experimental interventions.

Competing interests None declared.

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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.

Bordage G: Conceptual frameworks to illuminate and magnify. Medical education. 2009; 43(4):312–9.

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

Standards for Educational and Psychological Testing (American Educational Research Association & American Psychological Association, 2014)

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.

Tavakol M, Sandars J: Quantitative and qualitative methods in medical education research: AMEE Guide No 90: Part II. Medical teacher. 2014; 36(10):838–48.

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

The authors declare no competing interests.

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Lopresto: Our tips for how to get published as a medical student are first, choose a topic that you're passionate about. If you're passionate about it, you're going to love it. It's not going to seem like work. And you'll realize how much help you're actually doing in answering your research question.

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• v.17(1); 2012 Jan

Research priorities in medical education: A national study

Mina tootoonchi.

1- Instructor, Department of Medical Surgical, School of Nursing and Midwifery, Medical Education Research Center, Isfahan University of Medical Sciences, Iran

Nikoo Yamani

2- Assistant Professor, Medical Education Research Center, Department of Medical Education, Isfahan University of Medical Sciences, Iran

Tahereh Changiz

3- Associate Professor, Medical Education Research Center, Department of Medical Education, Isfahan University of Medical Sciences, Iran

Alireza Yousefy

Background:.

One preliminary step to strengthen medical education research would be determining the research priorities. The aim of this study was to determine the research priorities of medical education in Iran in 2007-2008.

This descriptive study was carried out in two phases. Phase one was performed in 3 stages and used Delphi technique among academic staffs of Isfahan University of Medical Sciences. The three stages included a brainstorming workshop for 140 faculty members and educational experts resulting in a list of research priorities, then, in the second and third stages 99 and 76 questionnaires were distributed among faculty members. In the second phase, the final questionnaires were mailed to educational research center managers of universities type I, II and III, and were distributed among 311 academic members and educational experts to rate the items on a numerical scale ranging from 1 to 10.

The most important research priorities included faculty members’ development methods, faculty members’ motives, satisfaction and welfare, criteria and procedures of faculty members’ promotion, teaching methods and learning techniques, job descriptions and professional skills of graduates, quality management in education, second language, clinical education, science production in medicine, faculty evaluation and information technology.

CONCLUSIONS:

This study shows the medial education research priorities in national level and in different types of medical universities in Iran. It is recommended that faculty members and research administrators consider the needs and requirements of education and plan the researches in education according to these priorities.

Medical universities in Iran are responsible for providing educational, research, and health services. They have to respond to the health needs of the Iranian society and modify their educational policies accordingly. Thus, planning for the desired educational research which is in line with their mission is very important. Educational research eventually tries to improve the practice of medicine by providing new evidence to be used by teachers and policy makers. It also provides evidence for educational bodies in their methods and approaches. 1 , 2 The importance of evidence for decision making has increased during recent years. In medicine, Evidence Based Medicine, and in medical education, Best Evidence Medical Education have been used to update educational policies and performances, and provide the opportunity for medical educators to monitor and standardize their existing programs within a quality improvement framework. 3 Therefore, educational researches must be planned in a way to provide legitimate evidence for educational decision making, teaching-learning process, educational management and reform. 4 Unluckily, in most Asian countries, educational studies receive a slight budget and face some barriers such as poor socio-economic condition, cultural and religious conservatism, leadership crisis, lack of relevance, low training in research and information poverty. Moreover, research committees in universities do not include educational studies among their top priorities. 4 A number of solutions have been proposed to strengthen medical education researches, one of which is to determine medical education research priorities.

Prioritization of research areas is so important that Ministry of Health and Medical Education in Iran and also a large number of vice-chancelleries for research in Iranian universities have announced their lists. 5 – 7 Essential National Health Research (ENHR) also, with collaboration of all Iranian universities of medical sciences and other stakeholders explored the national health research priorities and reported that researches in education encompassed 6.8% of total applied researches. 8 Most of these priority subjects originate from individual or institutional opinions or the faculties’ and administrators’ interests, and are not based on an organized research. The scope of medical education research is broad and depends on the needs and mission of individual institutions. 9 Medical Education Research Center in Iran is a national center with the responsibility to develop and manage educational researches in medical sciences. In this regard, determining research priorities largely contributes to guide medical education researchers and also to motivate policymakers and academic administrators to focus more on educational needs. Based on these priorities, one can recognize the needs, present problems, provide possible solutions and justify the priority of financial support for research. Since the main funding for research in Iran is provided by governmental section, there is a need for accountability in this regard which can be provided by priority setting as the first step. The aim of this study was to determine the research priorities of medical education in Iran.

This descriptive study was carried out during 2007-2008 in two main phases. In the first phase, the study population were the academic members of Isfahan University of Medical Sciences, while in phase two the faculty members of all universities as well as medical education experts participated in the study.

Delphi technique was adapted in phase one through three stages; each stage included forming small groups, distributing questionnaires and forming an expert panel. The Delphi method was used to involve a broad range of faculty members in all stages. The first stage was a brainstorming workshop in which 140 academic staffs, department heads, deans and their deputies on research and education, members of Education Development Offices at different schools, students of various educational levels, educational administrators of educational hospitals, and members of research committee in Medical Education Research Center were invited. Eighty nine people attended a one-day workshop on educational research. Having been briefed on educational research and its related areas, participants formed groups with 10-12 members each. The groups were benefited from supervision and guidance of one member of research committee. Finally, participants came out with a list of research priorities.

The topics were then refined and categorized and finally classified into different packages. A board of educational experts discussed the topics and categories in each package and a final set of topics was extracted. In the second stage, 99 participants received a questionnaire containing the finalized set of topics from the previous stage. These people, including workshop participants and deans and their deputies on research and education were asked to rate the topics from 1 (the least important) to 10 (the most important). The topics were identified and prioritized based on their averages; then, the priorities were discussed by a board of experts and refined again, providing the content of the next questionnaire to be used in 3 rd the stage of Delphi method. Seventy-six participants were asked to rate the items on this new questionnaire on a numerical scale ranging from 1 to 10. The obtained information was again analyzed and responses converged into a consensus position and became stable, therefore, final research priorities in the first phase were determined by the board of educational experts. These educational experts included seven persons holding the positions such as Director of Education Development Center, Manager of Medical Education Research Center, the University Vice-chancellor for Education, and four members of Research Council in Medical Education Research Center. It is worth to mention that these people hold at least a Master degree in Medical Education.

The second phase of the study was a cross-sectional survey in which academic staff and educational experts from all types (type I, II and III) of Iranian medical sciences universities were asked to rank the topics derived from phase one of the study. Experts and academic staff who were working for any Iranian medical university on permanent basis, on tenure track, on contract, the ones who had an educational managerial position or some position at Education Development Center, or were members of medical education board of experts were included in the study.

A total of 311 questionnaires were distributed among three types of medical sciences universities, from which thirty questionnaires were sent to medical education experts all over the country. Classification of medical universities in Iran are as follows: type I have the largest number of faculty members and students and they conduct the most undergraduate and postgraduates medical educational programs; type II have all of the above mentioned characteristics but at lower extents; and type III normally have very few undergraduate medical educational programs and no postgraduate ones in their system. 10 The questionnaires were sent to three universities of type I (n = 141), three universities of type II (n = 90) and two universities of type III (n = 50). In order to access the universities’ educational experts; first, necessary coordination were made with their EDCs (Education Development Centers) and consent letters were signed by EDC directors. Then, the questionnaires were sent to them and they were asked through an official letter to distribute the questionnaires among deans, education and research deputies of schools, the head of educational department, head of EDC, and education centers. The EDCs were also responsible to collect and return the filled questionnaires to Isfahan Medical Education Research Center by post with all costs paid. Data analysis was done by SPSS version 11.5. The results earned from the universities were merged with the viewpoints of medical education experts and the research topics earning top 25% priority rank were determined as top research priorities. Descriptive statistics was applied and mean and standard deviation were used for the analysis.

In the first stage of the first phase of the study, 927 topics were developed which were decreased to 129 research topics after getting refined by medical education experts and faculty members. The most important research topics in this stage were faculty member evaluation and promotion. During the second stage, from 99 distributed questionnaires 86 one were collected. The response rate of the second stage of this phase was 85.5%. Among 129 research topics sent to them as a questionnaire, the topics with more priority included: clinical faculty evaluation, promoting faculty members’ competency, faculty member's recruitment, faculty members’ responsibilities and roles, validity and reliability of faculty members’ evaluation methods, faculty development opportunities and faculty evaluation.

During the third stage of phase one, after refining the topics by medical education experts, 50 research topics were determined and the questionnaires containing these topics along with previous feedback were resent for 86 participants. The response rate at this stage was 81% and the questionnaire including these 50 topics was confirmed by educational experts to be used for the second phase of the study.

The response rate of the second phase in universities of type I, II and III was 75%, and 288 questionnaires out of 311 were collected. After the analysis, 12 research topics were determined as the highest priorities of medical education ( table 1 ). The best obtained score was 8.73 out of 10. The most important research priorities included faculty members’ development methods, faculty members’ motives, satisfaction and welfare, the criteria and procedures of faculty members’ promotion, teaching methods and learning techniques, job descriptions and professional skills of graduates, quality management in education ( table 1 ). Moreover, research priorities were determined separately in universities of type I, II and III ( table 1 ).

The scores of medical education topics from the educational experts’ viewpoints in Medical Universities according to their priorities

The topics earning the second top 25% of priority ranks included: brain drain from university, students’ educational needs assessment for curriculum developing, the gap between theory and practice, training practical skills in laboratory and skill lab, student evaluation methods in clinical and theoretical courses, curriculum revision in different levels and different educational disciplines, medical ethics in education and research, satisfaction and motivation of medical students, nurturing creativity and critical thinking, course evaluation and program evaluation, educational facilities and resources, health centeredness in medical education (medical education based on the priority of health maintenance and promotion), and faculty members recruitment and preparation for responsibilities.

The findings of this study showed the medial education research priorities in national level and also for universities of type I, II and III separately. The research priorities in different types of universities were a little different, because their educational situations as well as their needs are different. For example, the students to faculty members ratio and educational facilities varies in these universities. Although type III universities do not have graduate studies, the number of researches done in the field of medical education in those universities is considerable and we had to pay attention to their viewpoints in setting the priorities in national level.

An important issue in the present study was that the most priorities were concerning faculty members. As in priorities setting the view points of faculty members were asked, they mostly stated their own needs. In addition, lack of training for faculty members as well as lack of supervision and evaluation on their performance in the one hand and failure to provide opportunities for their growth on the other hand, caused this situation. However, recognizing faculty members’ problems, the factors causing these problems and proposing some interventions for solving these problems are among the most important studies in medical education. The problems concerning the methods and topics for faculty development programs in western countries have been discussed in other studies. 11 – 12 Medical sciences faculty members In Iran like many other countries do not receive formal training in teaching methods. 13 Thus, the Ministry of Health and Medical Education, and some other universities try to improve faculty members’ attitude and skills in teaching and research as well as to enhance their knowledge and skills in academic professional practice through running a number of workshops and courses. A systemic review on faculty development programs between 1980-2002, showed that these kinds of programs were effective and valued by participants 11 but paying attention to relevant topics and using appropriate methods in faculty development were recommended. 14 – 16 A study in Iran showed the most important development programs according to faculty members’ needs were information resources, clinical skills evaluation, and application of evaluation feed back in teaching. 17

Faculty members’ motives, satisfaction and welfare are also among the problems in Iranian universities. The role stressors such as role overload, role expectation conflicts, resource inadequacy, role stagnation, and role isolation were reported as high among Iranian faculty members. 10 A study showed faculties had the least satisfaction with their salary and rewards, promotion opportunities, physical condition and working environment. 18

The problems concerning faculty members’ promotion have been mentioned in other studies too. In a study performed in US, it was revealed that evaluation system and faculty compensation system were among the top items in which medical schools were most frequently making policy changes. 19 Some universities have developed criteria for faculty promotion and described the process for promotion and others have used E-forms for accurate evaluation. Despite these improvements, there is dissatisfaction with the appointments and promotions process in many medical academic centers. 20 , 25

Major developments in medical education research areas in the international level, include basic research about the nature of educational expertise, physicians’ professional practice assessment, problem based learning, continuing education and performance assessment. 26 However, research priorities in medical education have had an advancement based on periodical educational needs assessments during recent years. The trend of educational researches in South East Asia has shifted from competency based education, community oriented medical education, and self directed learning more toward continuous professional development and information communication technology. 27 A thematic review of medical education research literature in 4 famous medical education journals since 21 st century showed the areas of applied curriculum and teaching issues such as curriculum evaluation, teaching strategies and techniques, skills and attitudes relevant to structure of profession, students’ characteristics interaction with curricula, and performance and learning style differences, were most popular researches which community had been investing largely on them. 28 Therefore, periodic studies are needed to determine research priorities.

In Iran, less attention has been paid to medical education researches. In addition, investigating the published researches shows that medical education research priorities in Iran are a little different from subjects published in Iranian scientific journals during 1979-1998. 29 This could be due to the reason that published articles are mainly the subjects of interest for authors and do not exactly show the priorities. However, national Iranian Medical Council in a report about scientific researches, has ranked research priorities and presented 26 subjects among which medical education and its related subjects were in the 13 th position. 8 This little attention to medical education researches is not just for Iran. In a study by Tutarel on published papers, very few articles belonged to Asian context. Therefore, it seems that there is a big difference between developed and developing countries in medical education research priorities. In order to improve the quality of medical education and medical services, it is necessary to compensate for the information weakness. 30

In order to achieve these research priorities, it is recommended that educational researchers, faculty members, health managers, service providers and policy makers join each other to cooperate in developing strategies and identifying priorities to guide educational researches toward future and adopt social accountability based on that. 31 Our policy-makers should revisit our universities’ missions to assess nature, areas, and achievable goals of educational researches. Accordingly, research management can prioritize research areas and direct a wide range of research groups nationwide. The goal of determining research priorities is providing some indicators for helping in decision making, budget planning, and planning for future interventions. Therefore, it is recommended that managers and research administrators consider the needs and requirements mentioned by faculty members of different universities and try to guide medical education research projects accordingly.

The managers of Medical Education Development Centers in Iranian Medical Universities can take advantage of these priorities and introduce their needed subjects to faculty members, students and staff interested in research activities. Establishing expert committees in each university and determining research subjects and titles according to research priorities as well as providing a research map for improving the existing gaps can facilitate accessing evidence based educational information in each university. Although this study tried to have the participation of faculty members in different universities for determining the research priorities, medical students and other stakeholders had no role in this regard. This is while medical students are the main stakeholders of education and their views are important in educational planning and research. Moreover, medical students in Iran are engaged in researches in the field of medical education. Hence, it is recommended to plan future studies with the participation of medical students and other stakeholders, and determine research priorities every 3 to 5 years.

This study determined medical education research priorities in Iran. The priorities were more concerning faculty members’ problems, job description and professional skills of graduates, quality management in education, and clinical education which have been confirmed by literature too. Therefore, it is expected to plan educational researches based on these priorities to respond to the needs of the society.

Authors’ Contributions

MT carried out the design and coordinated the study, participated in all part of the study process and prepared the manuscript. NY provided assistance in the design of the study, coordinated and carried out the study and participated in manuscript preparation. TCh and AY provided assistance in data analysis and interpretation of data and read the manuscript critically. All authors have read and approved the content of the manuscript.

Acknowledgments

This study was approved and supported financially by Vice-chancellery for Research of Isfahan University of Medical Sciences (No. 0284049)

Conflict of Interests Authors have no conflict of interests.