Tensions Between Individualism and Holism: A Philosophy of Social Science Perspective

Despite the widespread implementation of competency-based medical education, there are growing concerns that generally focus on the translation of physician roles into "measurable competencies." By breaking medical training into small, discrete, measurable tasks, it is argued, the medical education community may have emphasized too heavily questions of assessment, thereby missing the underlying meaning and interconnectedness of how physician roles shape future physicians. To address these concerns, the authors argue that an expanded approach be taken that includes a focus on professional identity development. The authors provide a conceptual analysis of the issues and language related to a broader focus on understanding the relationship between the development of competency and the formation of identities during medical training. Including identity alongside competency allows a reframing of approaches to medical education away from an exclusive focus on "doing the work of a physician" toward a broader focus that also includes "being a physician." The authors consider the salient literature on identity that can inform this expanded perspective about medical education and training.

To develop a model linking the processes and outcomes of workplace learning. We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students. To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning. The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.

Authors have questioned the degree to which medical education research informs practice and advances the science of medical education. This study aims to propose a framework for classifying the purposes of education research and to quantify the frequencies of purposes among medical education experiments. We looked at articles published in 2003 and 2004 in Academic Medicine, Advances in Health Sciences Education, American Journal of Surgery, Journal of General Internal Medicine, Medical Education and Teaching and Learning in Medicine (1459 articles). From the 185 articles describing education experiments, a random sample of 110 was selected. The purpose of each study was classified as description ('What was done?'), justification ('Did it work?') or clarification ('Why or how did it work?'). Educational topics were identified inductively and each study was classified accordingly. Of the 105 articles suitable for review, 75 (72%) were justification studies, 17 (16%) were description studies, and 13 (12%) were clarification studies. Experimental studies of assessment methods (5/6, 83%) and interventions aimed at knowledge and attitudes (5/28, 18%) were more likely to be clarification studies than were studies addressing other educational topics (< 8%). Clarification studies are uncommon in experimental studies in medical education. Studies with this purpose (i.e. studies asking: 'How and why does it work?') are needed to deepen our understanding and advance the art and science of medical education. We hope that this framework stimulates education scholars to reflect on the purpose of their inquiry and the research questions they ask, and to strive to ask more clarification questions.