#KeyLIME Podcast 210: Do we have to have a theory? …‘there is nothing as practical as a good theory’ (K Lewin)

How can theory help provide insights into service–education tensions ? Read on, and check out the podcast here.


KeyLIME Session 210

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Cleland J, Durning S. Education and service: how theories can help in understanding tensions Medical Education 2019 53: 42–55.


Linda Snell (@LindaSMedEd)


Tensions between service and education have existed long after Osler said ‘the important thing is to make the lesson of each case tell on your education’, when workplace based learning evolved over a century ago.

There is a need for safe effective care while concurrently training future health professionals: service and education compete for limited resources, for teachers and learners alike. This is a global issue – increased practice and educational demands and regulatory restrictions mean less time is available for faculty to teach and for trainees to learn. This is also an area of interest to accreditation bodies who ask about ‘service-education balance’ – something that teachers, learners and curriculum designers may view differently.  The authors say the outcomes have been dissatisfaction of all parties and a move to jobs with less patient contact. There may be some alternatives (e.g. teaching teams, sim) but most education must be done in the clinical context, so we should examine how service and education can be aligned rather than being seen as competing activities.

The authors suggest that one of the reasons the tension persists is that this has been an area of medical education research (MER) that lacks a robust body of theory-driven research.


To conduct a search of the literature on service–education tensions since 1998 to examine the use of theory in studies on this topic.

Specifically they do a brief lit review / overview, then discuss how theory may help provide insights into service–education tensions by examining the application of four specific theories.


Narrative review, not to evaluate for rigour or outcomes but to look at study focus, use of theory and robust methodologies.

Scopus EMBASE, MEDLINE and PubMed databases in that order.

English language papers 1998-2018 focused on medical not health care education and training.

Key Outcomes

Search >> 603 papers  >> 44 (unclear how this was done)

Focus of papers 4 categories.

  1. describing the proportion of time residents spent on ‘service’ and ‘education’
  2. residents’ (or trainers’) perceptions of the balance between service and
  3. defining service and education
  4. studies identifying the impact of structural and systems changes (at a national or local level) on training and patient care

The dominant methodology was the bespoke survey, followed by descriptive qualitative inquiry.

Teacher and learner have different perceptions: residents report an overabundance of service. Both acknowledge that service activities can be educationally valuable. This is different from other workplaces where ‘service’ recognized as valuable.

BUT most papers don’t delve into different perspectives or how factors interact to cause tensions, and don’t use a theoretical or conceptual framework.

Now the ‘meat’ of this paper: using theoretical frameworks.


  1. Helps transferability and generalizability
  2. Helps develop robust explanations
  3. Can provide a link to previously investigated areas to increase understanding
  4. Can illuminate aspects of the issue

The authors apply 4 theories to this topic:  figured worlds; practice architecture; situated learning, cultural-historical activity theory. The explanation of why they chose these is that learning is social and participatory, so they used social learning theories, as these 4 view interactions, participants and the component parts of complex social settings in unique ways that can be leveraged to explore service–education tensions.

They do say the choices are idiosyncratic, drawn from research and education interests.

Can you think of other theories or concepts that might apply?  Communities of practice, social constructivism, experiential learning, prof identity formation, etc.

Table 1 explains theories and their application to our problem, with possible research questions. The authors also mention other possible theories from sociology, management, discourse.

Which you choose will depend on research interest or question, and researcher preferences. And the theory would dictate the research design.

Key Conclusions

The authors conclude…’The use of theory in research studies will not resolve service–education tensions. However, what theory can do is illuminate and magnify different aspects of service–education tensions, to generate new insight and knowledge that can then be used to inform future research and changes in practice’

Spare Keys – other take home points for clinician educators

Looking at the bigger picture, theory building and application is a basic and essential part of med ed research.

We are always told to include a theory (or 2) in our papers: this is often done retrospectively! Perhaps we should be doing this type of work first… but a caution: the choice should be more than idiosyncratic.

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