Lost in translation: why medical education research must embrace ‘real‐world’ complexities

There is little purpose in conducting research, or any enquiry, unless it has functionality beyond the realms of academia. In this commentary, I argue that there is an ongoing need for medical education researchers to revisit this claim, considering its implications for our discipline. To ensure education remains fit for purpose, the medical education community should reject a false divide between research focused on learner impact and research focused on patient impact. The emergence of translational research in, for example, the form of improvement (also called implementation) science to connect medical sciences with real-world practices should also be heeded as a warning. Unless we want the evolution of medical education research to continue its historical emulation of research in the biomedical mould, thereby creating a similar need for translational research, we must work in genuinely cross-disciplinary ways that engage with theory and practice, both clinical and educational. Without this our research endeavours will fail to have utility or uptake in the ‘real world’ of work and learning in health care practices. To avoid this pitfall I suggest we reconsider three themes crucial to high-quality, practically applicable education research. There is little purpose in conducting research, or any enquiry, unless it has functionality beyond the realms of academia Education to future-proof the delivery of individualised needs-based health care should commence with greater attention to the contemporaneous nature of workplace-based learning and health care delivery. Both happen in the same place, at the same time and with the same people. Education and health care are social activities, dependent on relationships among people and institutions. We should reject the positioning of workplace activities as being either patient-centred or learner-centred because good patient care and good workplace-based learning are relationship-centred, dependent on respectful collaboration and the negotiation of priorities and purpose. Appropriate patient care and the education of future professionals are not mutually exclusive. People learn spontaneously, whether they are in a ‘learning role’ or receiving health care, as a result of an intrinsic human need to make sense of life's experiences. The learning of professionals and patients today will affect the health care outcomes of the future. Recent reviews of poor health care highlight what happens when structural solutions are provided to problems dependent on human interactions.1-3 Dangers arise if people lose sight of the need to gain expertise through supported time for on-the-job learning of when and how to apply underpinning principles in health care. This is despite awareness that meeting educational needs can have direct positive impacts on patient care.3, 4 The learning of professionals and patients today will affect the health care outcomes of the future One of the strengths of education research lies in its power to explain complexities in the ‘real world’. Empirically informed education theory can help explain how and why complex social interventions may (not) produce targeted outcomes, particularly when used in combination with scholarship from the wider field of research in work and learning.5 Translation from research to practice should be at the heart of every education research activity, not a void to be filled, for better or worse, through serendipitous activities of educators. Researchers must strive to keep to the fore awareness that educators have to live and work in the gap between academia and the realities of daily clinical practice. There is little point in teaching ideals and aspirations for good clinical practice unless learners see these replicated by experienced clinicians in the ‘real world’. Rather than taking the translational role of the doctor-as-educator for granted, researchers should pay greater attention to workplace dynamics, and work collaboratively and critically with educators, patients and learners to ensure maximum benefit and minimum harm in education and direct patient care. Translation from research to practice should be at the heart of every education research activity We should also be wary of defining only certain methods of scholarship as true ‘research’. We must, of course, aim for the highest quality of (pragmatically achievable) research to inform and improve educational strategies and interventions. We should not, however, fail to acknowledge the lessons of the past, particularly with regard to spending undue time seeking to competitively contrast one methodology against another when in fact we need multiple research methods to address multifaceted questions. Almost 2 decades ago, Stokes6 argued that viewing research endeavours as a linear spectrum, from basic to applied, was unhelpful. Firstly, it encourages the polarisation of debate about which is of greatest value and should be given primacy when, in fact, society needs both. Secondly, to pursue a linear model to its logical conclusion results in the devaluing of research which seeks to simultaneously develop fundamental understanding and provide real-world utility (Stokes labelled such scholarship as residing in ‘Pasteur's quadrant’6). Medical education research can derive strength from operating in the messiness of Pasteur's quadrant and resisting categorisation into the persistent biomedical research models that have created a need for translational research. We should also be wary of defining only certain methods of scholarship as true ‘research’ We need to think more broadly about education in order to focus our endeavours on contemporary challenges in health care, such as the complexity of transitions for both patients and learners in clinical workplaces and the increasing complexities encountered in chronic illness and multi-morbidity. In any human endeavour the diversity of actions and interactions ensures the generation of unintended and unpredictable consequences.7, 8 Strategies for managing (rather than avoiding) risk and learning through appropriately graded responsibilities represent two areas in which we might strive to operate within Pasteur's quadrant in order to avoid disconnects between academics and practitioners, and learners and patients, and to usefully contribute to the development of safer and sustainable care. Medical education research can derive strength from operating in the messiness of Pasteur's quadrant For all of these reasons, medical education research has much to contribute to and much to learn from a world in which it is increasingly recognised that health care continually functions on the edge of chaos.9 Perhaps the challenge is to reconceptualise medical education as intrinsically an improvement science for complex social interventions. I suggest that to do this, medical education researchers should further their efforts to address three intertwined objectives. These are: (i) to develop a rich understanding of the social processes and interactions leading to knowledge construction and meaning making in the real world of health care practices; (ii) to generate empirically and theoretically informed suggestions for change in collaboration with patients, learners and educators in the real world, and (iii) to conduct rigorous studies of interventions which include evaluation of the realities of implementation and subsequent consequences. Without these actions, medical education research will not address the gaps between ‘should work’ and ‘does work’ and will remain prone to offering solutions without really understanding the problems we are trying to solve.