Partial truths – research papers in medical education

The papers contained in this issue of the journal are a selection from the rich and varied terrain of medical education. They concern both undergraduate and postgraduate education in a range of countries but nevertheless only cover a fraction of the breadth of the subject. In that simple sense the papers are partial. Without wishing to give offence to our authors, the content of papers should also be regarded as partial. Partial truth is a phrase that has come to be regarded as pejorative, implying that truth has been deliberately distorted and perverted by the selective revelation of information. Nothing could be further from the intentions of our authors, but the complexity and particularity of the educational processes and experience inevitably mean that experiments, descriptions, and evaluations in this field are at best reasonably accurate reflections of reality in specific locations at specific times. This leads some sceptical and perhaps cynical medical critics of education research to conclude that the studies are not worth the effort. This view of research values only scientific processes which give primacy to reliability over validity in experimental models which seek to concentrate on defined and isolated variables. In this paradigm, proper research is regarded as objective, hypothesis driven, with findings which are capable of general application. In clinical research the double blind controlled trial is regarded as the gold standard. The benefits of this method should not blind us to its limitations. First, it can only be applied in a relatively narrow range of clinical problems. It is not objective in the sense that the framing of the experiment introduces bias and distorts reality through exclusion criteria and the selection of the variables studied. The enthusiasm of the investigators, even in the best designed studies, can influence the environment in which the experiment takes place. Similarly, bias occurs in the selection of a particular hypothesis. Finally, the data produced in such studies concern means and medians of grouped scores. The relevance of such findings in guiding treatment decisions for an individual patient may be limited. Given the emphasis on biomedical research in medical curriculae, a temptation for doctors interested in medical education is to try to emulate quantitative scientific methods in assessing the effectiveness of educational innovations and interventions when qualitative research methods may be much more appropriate. Quantitative and qualitative research are not better or worse than each other, nor are they in competition. They are complementary. Quantitative research can help to answer the `how many, how often' questions but qualitative research can help to illuminate `why' questions. Doctors may dismiss qualitative research for its lack of objectivity, but action research, in particular, derives strength and power from its subjectivity. Who better to describe the twists, turns and complexities of an educational innovation than someone who has lived through the experience? What the reader of all papers needs to know is the starting point of the investigators. Did the findings refute or confirm their original expectations? Are the authors honest and transparent in their presentation of the available information? For all their apparent objectivity, all scientific papers are a form of polemic or rhetoric. They seek to make a case. Again this is not to impugn the authors. Passion, commitment, and hard work are needed to change the world and to change our perception of it. It is unrealistic to expect high-quality qualitative research suddenly to blossom in medical education. Mainstream education has a 30-year lead and is still struggling to maintain qualitative research in the face of political pressures to produce evidence of effectiveness in terms of examination grades. Undergraduate medical education does not equip doctors with the skills of qualitative research, nor yet with a sense of its value, even though clinical practice is qualitative in nature. In future in the journal we will encourage authors to state their beliefs and expectations in the introduction to papers as a way of helping readers interpret the findings and determine their relevance to their own institutions, locations and opportunities. We need partial truths to help us stumble forward in the complexities of medical practice and medical education if we are to avoid being guided purely by traditions, prejudices and power relationships. Finally, an apology from the Editor. Just as subjectivity pervades the papers submitted to the journal so does their assessment by referees and the final decision on acceptance by the Editor. Systematic bias and unfair discrimination are minimized through a variety of techniques but cannot be completely eliminated. Blinding referees to authorship is difficult in the field of medical education because the authors and the content of many papers are clearly linked. However, further work will be done to make refereeing as fair and as transparent as possible. In the end, given that the journal receives more than twice the number of competent papers we can publish, the final decision reflects the interest of the Editor and my anticipation of what will interest you. I am indebted to Zoe Jane Playdon, Ian Stronach and Esterby Smith for their stimulating presentations at a meeting on qualitative research. They will recognize their thoughts translated into this short editorial, and the least I can do in return for stealing their intellectual clothing is to provide references to their books (Smith 1991; Stronach & Machure 1997) which do this subject more justice than I have given it.