A Content Analysis of the Highly-Cited Articles in Medical Education: Commitment to Addressing Change and Reliance On Theory

Background: The medical education community is reecting increasingly on the role and nature of research in the eld. Useful sources of data to include in these reections are a description of the topics in which we are investing our energies, an analysis of the extent to which there is a sense of progress on these topics, and an examination of the mechanisms by which any progress has been achieved. The purpose of the present study was to provide an insight into the highly cited themes of research into medical education. Methods: This study is a content analysis of highly cited articles in medical education. An in-depth content analysis was conducted, identifying meaning units, which were compacted and coded with labels. Results: During a variety of topics, methods and strategies, 764 codes, 24 descriptive themes, and 7 categories were extracted from the content analysis as the most prominent. Categories for future medical education research were: Modern technology updating in medical education; Learner performance improving; Sociological aspects of medical education; Clinical reasoning; Research methodology concerns of medical education; Instructional design educational models; and Professional aspects of medical education. Conclusions: Medical education is in need of moving to a more theory and discovery driven approach and would from broadening and reformation that might bring answers to new An emphasis creating and models will nurture generalizable scientic knowledge and will increase medical education chance to drive the development of research on learning and instruction.


Background
While the citations received by scienti c publications have been used as a representative measurement to assess the impact of researches [1] and to rank researchers based on the differences in their citation indices [1,2], the numbers of published research papers and their citations have been used as a representation measure to assess the quality of research on national scales and to set it in an international context [3]. This may explain why highly cited publications are usually seen as in uential papers [4], not just for authors and journals but also for the universities and the nations where the work was completed [5,6] in terms of research productivity [6,7]. In practical terms, in the changing world of academic journals, citation ratings is one of the indexes of lasting, a real achievement, testament to the high quality of the published papers [8], and commitment to the usage of the historical knowledge of struggles tactically [9].
Highly cited articles usually bring to light new ideas or provide novel solutions to long-standing problems or tough questions. A large number of citations may also indicate that researchers rely more on such articles to qualify their methods or legitimize their views [10,11]. Furthermore, an objective algorithm based on citation data of high-impact researchers has been shown to help predict Nobel Prize winners [12,13].
Although the number of citations determines their article and journal impact factor and also researches tendencies and contributions [14], the number of citations does not necessarily re ect how in uential an article is in a particular area [15,16]. An article could be considered most in uential when it contributes to shaping aspects in a policy or a program, legislation, clinical practice, surgical procedure, or our understanding of a di cult concept [17]. Also, basic and dominant research methodologies in each domain and at speci c time intervals have the potential to receive high citations. As an additional point, these parameters together with social consideration and the role played by media may restrain the in uence of an article [18].
Highly cited articles have had a major in uence on the evolution of scienti c debate, delegation of the dominant discourses, and expansion of current practices [19]. They are also knots in the network of dissemination, acceptation, discussion, and practices of scienti c and educational information to identify power relations between knowledge and social practices [20]. Therefore, the identi cation and analysis of the highly cited articles provide us with a range of information not only about the topics and themes covered, problems solved, and methods used, but also about their prominent properties, what can be learnt from these articles and where to go from here [18]. From an application perspective, by revealing the classi ed tenets and diverse perspectives of the highly cited articles, educational researchers and educators are stronger, smarter, and better prepared for the challenges [21,22].
The aim of the present study was a content analysis of the highly cited articles in medical education to develop a unifying portrait of classi ed themes and contents that could inform a common set of chances and challenges, based on their future roles in academic society. The rst medical education research content analysis has covered 1975-1994 period [22], the second has investigated articles published during the years 1988-2010 [21], and the present 2009-2018 content analysis together have prepared a holistic perspective from 1975 to show prominent themes, order of priorities, and changes over time.

Search strategy and study design
This study is a content analysis of highly cited articles in medical education. The Science Citation Index Expanded (SCI-Expanded) database of the Thomson Reuters Web of Science search on12 June 2019 was used for the identi cation of highly cited articles, because this is the only database that gave us a reliable criterion for elite articles selection. Among the 34 journals were listed in the "Education, Scienti c Discipline" category of Web of Knowledge, 19 journals' scope were related to medical education. The search formulate in the eld of publication name was: ((Academic medicine (US)) OR (Advances in health sciences education (Canada)) OR (Advances in physiology education (US)) OR (American biology teacher (US)) OR (American journal of pharmaceutical education (US)) OR (Anatomical sciences education (US)) OR (Biochemistry and molecular biology education (US)) OR (BMC medical education (UK)) OR (CBE life sciences education (US)) OR (European journal of dental education (UK)) OR (Hematology American society of hematology education program (US)) OR (Indian journal of pharmaceutical education and research (India)) OR (Journal of biological education (UK)) OR (Journal of continuing education in the health professions (US)) OR (Journal of surgical education (Canada)) OR (Medical education (Canada)) OR (Medical teacher (UK)) OR (Nurse education today (Australia)) OR (Teaching and learning in medicine (US))).
From 59,030 retrieved results, 77 articles have been classi ed under the highly cited paper category. As of May/June 2019 this category updating, these highly cited papers received enough citations to place in the top 1% of the academic eld, based on a highly cited threshold for the eld and publication year (from 6 citations at 2018 to 605 citations at 2009). By omitting three irrelevant articles that have not covered educational aspects of medical sciences, 74 relevant highly cited papers were subjected to content analysis.

Data analysis and credibility
An in-depth content analysis was conducted, identifying meaning units, which were compacted and coded with labels. The process was started through reading each article several times in order to extract both its general and retail concepts and missions. By repeated browsing across extracted codes, the structures of themes were crystallized gradually based on construction and deconstruction tradition.
Similarly, themes with conceptual similarities were grouped into categories in a similar way. Each of themes was de ned and illustrated with representative quotes from the papers [23][24][25][26].
An international and multi-disciplinary team (from medical education, linguistics, education, and nursing) was engaged in this content analysis as an enlighten preface and part of a lager study in order to cover the most widespread and different points of view. To ensure validity and thoroughness, after content analysis was carried out independently by two authors (PhD thesis's internal supervisors); all were classi ed and coded by the lead author (PhD candidate) and were second-coded by two of the other authors (PhD thesis's external supervisors). The lead author met with each of the other coding authors to assimilate differences in coding by consensus. If consensus could not be reached, a third author (PhD thesis's advisor) who had not coded that transcript helped to simplify reconciliation. Themes and categories have been evolution in similar ways.

Results
The purpose of the present study was to provide an insight into the highly cited themes of research into medical education. In addition, the journals, organizations, funding agencies, authors, and methodologies most often involved in medical education research were to be identi ed. Retrieved highly cited articles have been distributed between 2009 to 2018 as Table 1. Such distribution of highly cited articles over the past ten years does not follow a speci c pattern. The ndings showed that in addition to the selected web of science category, the majority of highly cited papers have overlapped -with other categories as: "Health care sciences services" with 46 papers, "Education, educational research" with 10 papers, "Surgery" with 4 papers, "Physiology" with 2 papers, "Nursing" and "Pharmacy", each with one paper.
There was a relationship between the corresponding journals containing the most highly cited articles and their impact factors, as Table 2. An over representation of 10 USA journals were the half more, while the UK and Canada with respectively 4 and 3 journals, and Austria and India each with one journal were the half less. Advances in physiology education (US) 2 Journal of continuing education in the health professions (US) 2 American journal of pharmaceutical education (US) 1 Nurse education today (Australia) 1 Top organizational a liations were related to USA and Canada respectively, with undisputed domination of organizational a liations of USA (Table 3).    During variety of topics, methods and strategies, 764 codes, 24 descriptive themes, and 7 categories were extracted from the content analysis as the most prominent. Some descriptive themes were shared among several groups, which were classi ed under the dominant group (Table 7). Simulation-based mastery learning in medical education can produce downstream results and translational outcomes in terms of improved patient care practices, better patient outcomes, and collateral effects.
Learner performance improving: 16 articles Academic performance reform: 5 articles [49][50][51][52][53] New calls for academic performance reform are emerging for: (1) standardizing learning outcomes and individualizing the learning process, (2) promoting multiple forms of integration, (3) incorporating habits of inquiry and improvement, and (4) focusing on the progressive formation of the physician's professional identity.
Advancement of educational outcomes: 3 articles [54][55][56] Mapping and measuring programmatic outcomes alongside promoting and guiding curricular change were achieved by a structured framework provided by CME activities in order to address issues of competence, performance, and patient health status.
Erosion of empathy: 3 articles [57][58][59] Erosion of empathy occurs during a time when the curriculum is shifting toward patient-care activities, compromises a disagreement striving attempt toward professionalism and clinical competence, and may threaten patients' clinical outcomes and health care quality.

Burnout: 3 articles [60-62]
An environment in which trainees ourish, achieve high wellbeing and acquire the skills necessary to promote resilience is clearly needed. Identity formation is a dynamic process achieved through socialization; it results in individuals understanding the nature of professionalism and its obligations and internalizes joining the medical community of practice and the value system of the medical profession.  70] Institutions must examine the climate for women to ensure their academic capital is fully utilized and equal opportunity exists for leadership.
Race/Ethnicity differences: 1 article [71] Successful retention of underrepresented medical (URM) faculty requires comprehensive institutional commitment to changing the academic climate and deliberative programming to support productivity and advancement. Academic medicine's ability to change sexual harassment must work to begin to establish safe environments for individuals to come forward, to provide training for victims and for bystanders, and to abolish locker room talk that is demeaning to women. Dual Process Theory (DPT) has immediate application to medical decision making and provides an overall schema for teaching decision theory.
Trainers trust: 2 articles [77,78] Trust allows the trainees to experience increasing levels responsibility and can serve as signi cant stimuli for learning and also shape the assessment of trainees. Statistical signi cance is the cornerstone of quantitative researches, but studies that fail to report measures of effect size are potentially missing a robust part of the analysis. Also despite frequently criticisms, the choice of statistical methods can be utilized without concern for getting the wrong answer. The medical education community has an important challenge to take full advantage of the outstanding new resource as educational research datasets with the potential to radically change the volume and types of research that can be envisaged and, therefore, to improve standards, facilitate workforce planning and support the regulation of medical education and training. Competency-based medical education, as a resurgent paradigm, relies on continuous, comprehensive, and elaborate assessment and feedback systems which facilitate the developmental progression of competence and has the potential to transform contemporary medical education.
Interprofessional education (IPE): 2 articles [99,100] There is growing interest in IPE and in its education and research agenda to develop best practice models based on evidence of effectiveness that must not be regarded as distinct from the agenda de ned by the needs of health care practice and patient care.

Discussion
The purpose of this study was to examine the highly cited articles on medical education and to identify dominant trends in this body of research. In addition to which areas are relatively more or less valuable, it is equally important to address why the community might see them as noteworthy and how we could take advantage and see the value-added of the results. Rather, the objective of such research is not, by itself, to effect change, through this will come. The attempt is to provide some kind of framework in which informed change could result, with the conviction that when change is the result of the best evidence available in the format of highly cited articles, it is more likely to produce the desired outcome than if it is based on untested assumptions or bene ts. Administrators and lobbyists can work jointly toward the accrual of political and economic support for key areas of research and development. Researchers and developers also must do their part to work programmatically, both individually to pursue promising ways of thinking and lines of research and collaboratively to build mutual understanding.
First, twenty-three descriptive themes of highly cited articles in seven categories were identi ed. More than thirty percent of the articles counted deals with modern technologies and their implications in one way or another. Categories for future medical education research were: Modern technology updating in medical education; Learner performance improving; Sociological aspects of medical education; Clinical reasoning; Research methodology concerns of medical education; Instructional design educational models; and Professional aspects of medical education. These seven areas suggested for further research inquiry represent a continuum of processes and technologies in medical education and practice.
Research in medical education in the future should be focused on the inter-relationships of such educational processes with technological, sociological, and professional aspects.
As medical schools become increasingly committed to and involved in direct responsibility for providing care to a variety of populations, it becomes increasingly urgent to understand how various educational processes and technology-based innovations affect each other and do or could in uence the career patterns, learning outcomes, and performance behavior of the trainees and graduates of medical education while investigating how modern technologies and their implications, sociological and professional aspects, and methodological concerns in uence such characteristics. This broad scope of topics has the advantage of providing many opportunities for diverse range of research and discovery, but it also generating a sense that the eld lacks coherence and communal effort toward the resolution and advancing of big questions.
Second, the US journals, organizations, funding agencies, and authors were produced most of the highly cited researches in medical education. This was to be expected because medical education research created and expanded in this country rst, the number of medical schools and organizations in the US is sizable, and US medical schools tend to be research intensive and this attitude tends to spill over to the departments of medical education. In addition, the editors of each of the journals have been active in their pursuit of promoting and shaping the face of medical education research. It is, therefore, surprising to note that Canadian journals, organizations, and authors were appeared in the top of highly cited articles with a stark difference from US. Clearly, in spite of gross premier of medical education research in US, medical education research is a more international endeavor than many other medical domains.
The most highly cited papers were reviews of the literature rather than research articles. The archival approaches including perspectives, synthesis of review literatures, and systematic reviews, with 44.6 percent of highly cited articles was dominant. This recent trend is seen as a very positive outcome that will assist policymakers, investigators, and teachers to adoption, development and evaluation of new educational approaches.
Research methodological concerns approved the need for continuing feed-in of good research that is problem oriented, comparative, and longitudinal, focused on qualitative paradigm and information management methods. Also, most of the highly cited articles (54/54 %) reported outside funding support.
The half less incidence of external sources may be compatible with the picture of school-sponsored educational studies at an individual institution ( Table 4).
The average number of authors per article was 4.98. Undisputed domination of American authors in the most highly cited articles authorship was hegemonic ( Table 5).
The average number of authors per article (4.98) has grown over the past decades, and this growth may be an indication of increased collaboration between medical educators with faculties of basic science and clinical teaching.
Third, it is interesting to compare the distribution of topics regarding the pursuit of knowledge-building in a community of scholars with the recommendations in previous essays. A majority of the medical education's articles between 19975-1994 fell into three broad categories: curriculum, teaching, and student assessment. A large percentage of them focused on performance assessments, assessments of medical student competence, or studies designed to compare educational methods [22]. These three topics were surprisingly under presented in the 1974 essay's ve areas including selection of physicians, medical school socialization process, house o cer training, medical schools as social institutions, and physician performance [101]. Student assessment, clinical and communication skills, clinical clerkships, and problem-based learning were the most prominent domains of 1988-2010, in which the community has been investing its energies.
Assessment of students, with reliability and validity of the measures employed, were the premier concern.
Some of themes, such as multiple-choice examinations or computer-assisted instruction seemed to have had their day, whereas other topics, such as the study of clinical clerkships, clinical reasoning, and scholarship in education were on their way up [21]. Perspectives concerning a eld-based inquiry approach to medical education were offered in the 1988 essay. This approach required that inquiry tactics more closely match educational and clinical processes. It was concluded that understanding of social and educational phenomena had too long been determined by research and evaluation frameworks that de ne concepts of what is good and what is bad in medical education and that have limited those concepts. Most medical education research organized by constructs, typically psychological or behavioral, that were used to explain or predict certain patterns of human behavior [102].
During the process of re ecting on the medical education research literature since the turn of the 21th century, four themes jumped out as being very apparent including curriculum and teaching issues, skills and attitudes relevant to the structure of the profession, individual characteristics of medical students, and the evaluation of students and residents. The lines of research related to the content area of professionalism and those related to the development of the OSCE were obvious, at least in part because of their apparent coherence as a domain of research and development [103].
Fourth, there was very little evidence of overarching theories of education that direct and inform the individual studies between 19975-1994. One of the concerns since the turn of the 21th century was that the eld did not seem to be advancing on "big questions" and expanding systematic or productive programs of research. The lack of research studies that incited and appraised by useful theories or the absence of "functional" theories were resulted to the di culty of aggregating ndings into consistent themes. One solution for this issue would be to look at domains, themes, and mechanisms where the medical education community has recently invested their research and development energies through community-level re ective practice by which improvement has been achieved and theory has played a role.
Fifth, it is interesting to note that assessment as a key domain identi ed from 1975 to 2010 does not attract much attention. It is possible that this has been studied extensively in bygone eras and has not any longer been considered problematic. Although assessment is still counted but its hegemonic prominence and axial role were marginalized and the power and authority of clinical assessment were delegated to modem technologies' implications, especially in anatomical sciences education. The same may apply to the use problem-based learning, in the nineties and rst decade of 21th century as a core issue in medical education. Comparing the chronological of PBL a rmation and the relative lack of emphasis on lectures and computer-assisted instruction with multimodal teaching approaches, its special attention to the tension of clinical and basic sciences instruction, and nally its prominent elimination are perhaps witness of the amount of enthusiasm and controversy that PBL approach to medical education surrounds. Interestingly, methods based on modern technologies such as multimodal teaching approaches, technology-enhanced simulation-based mastery learning (SBML), and 3-Dimensional printing models now emerge as approaches deserving notice. Such modern technologies served through instructional design educational models such as ipped classrooms (FC) or increasing course structure (ICS). Healthcare and medical training have no immunity to universal and rapidly changing technology. In medical education, advances like multimedia applications through modern educational models (FC and ICS), simulations (integrated simulators with part-time trainers, and virtual reality), and 3D printing models (immersed in various technologies) have evolved as pedagogical strategies to facilitate an active and learner-centered teaching approach.
Professional aspects of medical education category consist of competency-based medical education (CBME) and inter-professional education (IPE) in order to performance improvement. Within the broader learner performance improving category, most articles have been devoted to academic performance reform, advancement of educational outcomes, erosion of empathy, burnout, and effective selection policies and methods. Therefore, issues of optimizing clinical competence, both in terms of diagnosis and management and in terms of the clinical and interpersonal skills, are vital to those involved in such education. The medical education highly cited articles show an overwhelming emphasis on the effectiveness of modern technologies in medical education reforms and direct preparation of students for improved professional practice and outcomes. Modern technologies can address the educational goals in medical education include facilitating basic knowledge acquisition, improving decision making, enhancement of perceptual variation, improving skill coordination, practicing for rare or critical events, learning team training, and improving psychomotor skills.
With regard to teaching methods, focus is transforming from clinical phase to the basic sciences phase of medical education with its increasing technological potential. Teaching of clinical phase is also transforming from the clinical and communication skills and the clinical clerkships to broader clinical reasoning category including diagnostic cognition and errors, and trainers trust and feedback. Clearly, clinical reasoning, continue to attract interest over time. Cognitive psychology with technology acceleration role in uences on the attempting to identify how information is leaned by students and later retrieved in clinical contexts. Research methodological concern is the third transformation focusing on qualitative paradigm based on information management technological approaches. Yet, not all of today's medical trainees or educators are equally adept and comfortable with technology in the basic sciences and clinical education and research. Educators are tasked with selecting and ltering appropriate technology-based curricula.
The fairly recent interest is sociological aspects of medical education that categorized into professional identity formation (PIF), social determinants of health (SDOH), gender differences, race/ethnicity differences, and sexual Harassment. Topics such as professionalism in medicine and the possible role of the humanities in medical education were already noticeable in the 1988-2010 literature. This seems to be largely due to politico-cultural distinctions between the new and the old world. Technologies are some of the techniques available to administer the changing educational and social environment and can supply and support the infrastructure and basis for operating many of the challenges in preparing medical education community for the future.
Sixth, the most highly cited researches conducted in medical education seems to be effectiveness-driven and checks the comparative effectiveness of existent approaches rather than discovery-driven and detect new ones. Four innovations including multidisciplinary-multimodal teaching approaches, technologyenhanced simulation-based mastery learning (SBML), 3-Dimensional printing models, and ipped classrooms (FC) educational models have emerged from the highly cited medical education articles. These innovations have been fallen prey to the same effectiveness virus and are aimed at justi cation of ideas rather than clari cation. A domain such as clinical reasoning, which has shown consistent and monotonic growth about four decades is a prototype of a progressive research domain that arise from a change to new paradigms that create new and interesting questions.
Inquiry processes operate in a fashion parallel with the nature of social and human practice and systems. All forms of educational and social inquiry seem to be focusing on the eld as a framework and basis for inquiry. The description of medical education instruction is based on research that combines concepts germane to adult learning theory and medical education. The key point is that there is a legitimate match among certain features of medical education, clinical practice, and inquiry that justify use of a less "scienti c" more eld-based research approach in medical education settings.

Conclusions
Commitment to change educational emphasis and concerns, transformation of competencies and processes, and reformation of educational systems and designs were repeatable component of highly cited articles content. Reliance on theory and theoretical frameworks were the second turning point of this content analysis that has provided rich archive of valid evidence for education and research. Overall, medical education is in need of moving to a more theory and discovery driven approach and would pro t from broadening its scope and reformation that might bring answers to new concerns. We have realized that the system is awed and science change will take time. An emphasis on creating more systemic knowledge and theoretical models will nurture the generalizable scienti c knowledge and will increase the medical education chance to drive the development of research on learning and instruction. The ultimate goal of medical education is to nd better ways to teach, to modify some aspects of performance, and to improve interventions or programs within medical education. So we rst need to make sure that we develop explanatory theories, identify and cluster instructional support methods into theoretically related ones, and nally investigate them systematically.

Abbreviations
Science Citation Index (SCI), Accreditation Council for Graduate Medical Education (ACGME), Simulation- involves the author's contribution to the study). All to have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
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