Julie Browne

Socio-Cultural Learning Theories

L. P. Hartley’s novel The Go-Between has a stunning opening line: ‘The past is a foreign country.’ This suggests at least three readings: first, do not bother with history as it is already alien territory; second, if you visit history you can always reclaim it as your own, as one country might colonize another, imposing the victor’s version of events; and third, we must engage with history as if we were entering a foreign country—as aware and sensitive guests. By now, readers will be aware that we think it is a good idea to engage with history, to invite history in as a welcome guest and to get to know this guest through offering unconditional hospitality (the original meaning of the ‘hospital’). To move forward, medical education must be aware of where it has come from. As we suggested at the beginning of Chap. 1, it is important to articulate how dominant approaches to medical education came into being and what happened to legitimate challenges to such dominant views. This allows us to track influences of power.

Global Medical Education—A Post-Colonial Dilemma

Our final location for medical education in this trio of chapters on matters of place/place matters, offers a paradox. It is both everywhere and nowhere at once. Global, or international, medical education is, we suggest, in danger of being homogenized through virtual (online) programs. More importantly, regardless of the medium of delivery, ‘whose’ medical education is being delivered? Who decides on the nature of the message? Is the pedagogy of a global medical education actually a Western export, offering a neo-imperialism or neo-colonialism by the back door?

Place Matters: Location in Medical Education

In this and the following two chapters, we link location with identity and power in medical education. Place or location is considered from seven perspectives:

Learning by Simulation and the Simulation of Learning

In this chapter, we continue the theme of location for medical education, but now move away from work sites such as hospitals, to the clinical skills centre. Here, learning by simulation has become the dominant teaching method.

Learning from Learning Theory

If you watch a skilled artisan at work, such as a master butcher, there is an obvious internal coherence to the execution of the skill. It is economical, fluid, elegant and—above all—paradoxically restrained. There is no need for flamboyance. The knife-edge seems to ‘fall’ into the meat. The best artisans are at one with both their tools and the objects of their endeavors. They do not force. Indeed, there is a sense of minimal interference from the hands, a kind of ‘lifting off,’ where the specific qualities of the tool do the work, such as the weight and sharpness of a heavy cleaver blade. Paradoxically, while ‘grip’ may seem key to controlling tools, it is ‘release’ that distinguishes the expert from the novice. The novice’s grip is too tight—taut and fearful rather than relaxed and confident. As Sennett (2008, p. 152) points out, ‘grip’ and ‘release’ are also powerful metaphors for ethical relationships. Good teachers never control with a tight grip, but offer guidance and encourage learner autonomy. They are confident that ‘release,’ or ‘lifting off’ from something rather than pressing, will create positive space for safe practice and innovation. Above all, they do not oppress, offering supportive ‘presence,’ not force.

Beyond Practical Reasoning

What is a ‘medical education’ and is this the best generic descriptor for the practices that support the learning of medicine? Ludmerer (1999, p. 311) points out that in 1988 the Association of American Medical Colleges (AAMC) ‘abandoned its learner-centered outlook for a faculty-centered outlook,’ and re-defined its mission—from ‘the advance of medical education and the nation’s health’ to ‘the advancement of academic medicine and the nation’s health.’ In 1989, the Journal of Medical Education was re-named Academic Medicine. Medical education had become subsumed in a wider interest, or, more specifically, the practice and scholarship of teaching was formally subordinated to academic research interests, albeit in educational issues. The clinic and its various practical pedagogies were subsumed in the university and its academic pedagogies.

Medical Education as Patient

Predicting the future of medical education, suggests Eva (2008, p. 330) is a ‘fool’s task,’ where ‘the most likely outcome promises to be embarrassment for the prophet.’ We tend to agree with Eva that we may all be better off in medical education for ‘covering up the crystal ball.’ However, in this book we make no claims for prophecy; rather, we are interested in Michel Foucault’s idea of a history of the present. This approach maps out the conditions of possibility for the emergence of particular ideas and practices. As Foucault (2005, p. 9) puts it:

Let’s Get Real: Medical Students Learning from, with and About Patients

One of the striking features of Stewart’s (1995) review of the literature on patient health outcomes as related to quality of doctor–patient interaction is that the most powerful form of relationship is neither strong paternalism nor strong patient autonomy, but strong doctor–patient dialogue. The optimal ‘care formula’ for the medical encounter is not just doctor plus patient, but doctor times patient. While this may seem self-evident, the cumulative research evidence suggests that the majority of doctor–patient interactions do not follow this formula (Roter and Hall 2006).

Identities, Powers and Locations: What Does the Future Hold for Medical Education?

In the final two chapters, we summarize our argument for a new approach to medical education and move beyond our concerns with pedagogy to engage with policy. In setting out what the future may hold for medical education, we describe in the following chapter the ground—provided by academies—upon which pedagogy and policy can engage in creative dialogue. We argue that medical education can and should be constructed differently than it is at present. Certain critical changes are already in the air, but we believe that more can be done to shape a responsive and socially responsible medical education for the future, while unproductive habits from the past persist and need to be challenged.

Lack, Trajectories and Ruptures in Medical Education Research

In a roundup of ‘what the educators are saying’ in the British Medical Journal, Lough (2006, p. 1450) commented on a ‘rare editorial on medical education’ in the Lancet (Davis and Ponnamperuma 2006), also referred to in Chap. 1. The editorial, by Davis and Ponnamperuma, suggests that medical education research is ‘at a crossroads’ as it ‘struggles for recognition.’ In summarizing this ‘shaky position,’ Lough points to a need to overhaul such research in a dog-eat-dog culture of ‘chronic underfunding.’ Individual studies, he argues, need to be abandoned for multi-center collaborations to establish a critical mass. Best evidence education needs to be promoted by medical schools otherwise the research outcomes simply fall into a practice vacuum, with no benefit for patients. Finally, there is a chronic need for education programs for researchers to improve their skills and understanding in the field. Importantly, it is through collaboration, rather than multiplying up competition for resources, that research may progress. We see an important implication of this trajectory for medical education research—paradoxically, in a field that is increasingly competitive, the funded research process can act as a democratizing force for medical education because it can promote collaboration.