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 benefits. 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 identified. 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 influence 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 influence 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 field 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 first, 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 . These three topics were surprisingly under presented in the 1974 essay’s five areas including selection of physicians, medical school socialization process, house officer training, medical schools as social institutions, and physician performance .
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 . Perspectives concerning a field-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 define 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 .
During the process of reflecting 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 .
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 field 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 difficulty of aggregating findings 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 reflective 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 identified 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 first decade of 21th century as a core issue in medical education. Comparing the chronological of PBL affirmation 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 finally 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 flipped 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 influences 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 filtering 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, technology-enhanced simulation-based mastery learning (SBML), 3-Dimensional printing models, and flipped 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 justification of ideas rather than clarification. 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 field 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 “scientific" more field-based research approach in medical education settings.