Reflections on our current history

Field: Health Professions (Health Sciences)

Editor's note: This is the sixth editorial in a series that offers a retrospective look at the 50 volumes of Medical Education through the lens of each Editor's tenure. Kevin Eva has been Editor in Chief from Volume 42 in 2008 to the present. For the preceding editorials in the series click ’read’ at www.mededuc.com. And, lastly, it's my turn. As Medical Education nears the conclusion of its 50th volume celebration, it seems long ago that I wrote1, 2 and commissioned3-5 editorials reflecting on the periods of the journal marked by each Editor in Chief's tenure. As the sixth and current person to hold that role, I have the challenge of offering reflections on the state of health professional education (HPE) from 2008 (when I began) to the present day. I do so well aware of the many warnings that suggest events or activities cannot properly be put into perspective without the passage of time and with considerable uncertainty about how to comment meaningfully on a large and varied field in relatively few words. When I pause to reflect on my perceptions of HPE during my term as Editor, my mind continually returns to two words: growth and diversification. I do not believe either of these things began in 2008, but I do think both have intensified. In the past 9 years we have received more submissions to the journal than were received in the entirety of the preceding 41 years. With respect to diversification, I daresay that Sir John Ellis and his founding team did not need to make sense of everything from autoethnography to structural equation modelling. There are of course many dimensions across which HPE should strive for even greater diversification, but for my reflections in this editorial I would like to draw attention to a few of the effects I believe the field has experienced as a result of growing interest and epistemological/methodological expansion. First and foremost, I think we have to posit that growth and diversification have deepened the state of tension that Rangel et al. described earlier this year.6 With more people coming to the field from more heterogeneous roles and backgrounds, it is no surprise that contradictions abound: while some argue for greater rigour, others argue for the need to be flexible; while some argue for more sophisticated theory, others desire more straightforward practice guidelines; while some prioritise innovation, others insist upon mounds of evidence; while some reflexively dismiss work that does not derive from their particular context, others rail against insularity. There is growing appreciation that few tensions should be conceived of as dichotomies that lie at different ends of continua,7 but these tensions still pose challenges when operating in a diverse field. As an author, they create difficulty because no matter what one writes it can be criticised as being insufficient simply by adopting a different perspective. As an editor, it can seem as though your main role is to keep everyone slightly unhappy. As an optimist, however, one hopes that such contradictions produce for the field the ‘productive tension’ that Collins has found to be a feature of great companies that stand the test of time.8 While we prepare for the next 50 volumes of the journal by reflecting on where the field is currently, it is worth taking a closer look at this concept of tension. In the way that Collins,8 Rangel et al.6 and I have used it,9 the term tension alludes to conflict between different positions that cause strain or stress and might yield positive outcomes. From the bridge engineer's perspective, however, tension is merely a force that pulls outward and can have nothing but disastrous consequences unless offset by an equal and opposite force. I believe that it is efforts to balance such opposing forces that define the best the field of health professional education has had to offer over the course of the past decade and that create the mechanism through which positive outcomes might be achieved as we move into the future. At this point in history, the theoretically minded individual who cannot offer a compelling argument for how her research connects with the educational needs of the health professions deserves to be segregated and the practically minded individual who cannot see the value of contemplating different ways of thinking deserves every charge of narrow-mindedness that is sent his way. With each passing month we have greater access than ever before to the knowledge held by others, both through formal literature and more social technologies. This has made it impossible to justify any project by arguing ‘There is no relevant work in this domain’ while still claiming to balance both conceptual and pragmatic thought. Similarly, over the course of the last decade I have largely lost sympathy with the argument that the field is too conventional to allow ‘outside the box’ thinking. If any field is diverse enough to respect unique ways of viewing the world it is health professional education. As we come to appreciate that the practice of science is less about adoption of particular methodology and more about evidence-informed storytelling, there is an onus placed on the storyteller to recognise that understanding depends entirely on what the listener (in this case our reviewers and readers) already believes. The field's understanding needs to change in some regards, but as authors we would all be wise to heed Walter Isaacson's response when someone claims a kinship to the misunderstanding suffered by Einstein: ‘to think outside the box effectively you first need to understand what's inside the box’.10 A challenge this continues to create, particularly for those who are new to health professional education, is that the first step towards understanding relevant phenomena probably seems greater than it was to those of us who have been here a while. This, combined with the fact that most people continue to come to HPE through serendipity,11 makes it increasingly critical that those within the field point newcomers to smoothed paths, warn of cliffs, and provide substantial encouragement. The continued professionalisation of the field has been furthered in the last decade by a mushrooming of formal training programmes,12 but we must strive to keep the less formal collegial and collaborative cultural norms that have distinguished our field from many others I've encountered. It is heartening in this regard to note that the establishment of teams of investigators with complementary expertise, often from different institutions or countries, has become commonplace. Rarely in the last decade has Medical Education published single-authored research papers. That trend has not been driven by editorial choice or policy. Rather, it seems to have been driven by the difficulty inherent in any one individual trying to personify all of the perspectives and skill sets that are required to effectively compress divergent ideas and experiences into coherent research questions, rigorous methodologies and compelling stories that have conceptual and practical significance. Our goal in continuing to encourage such collaborations should, after all, not be to make our work easier, but to make it better. For beginners in the field who are reading this to try to get a head start towards understanding health professional education, I wish I had learned enough over my term to date as Editor that I could offer you a strategy that would guarantee you all the success you desire. Alas, as I've reflected on the many forms of scholarship that have made valuable yet diverse contributions to our field in the past decade, the best advice I can offer based on the success stories I've seen is to follow your passions, to be sceptical, to remain humble and to embrace uncertainty. After all, if the tensions seen during our current history as a field were to resolve it, it would be a negative sign of splintering rather than an indication of the continuing progress to which you will hopefully contribute.