In the editorial of the previous issue of Revista de la Fundación Educación Médica, I mentioned that on 20 January 2023 a farewell symposium for Professor Cees van der Vleuten, a leading figure in international medical education, would take place at Maastricht University on the occasion of his retirement. I was able to follow it online. At this event, which was attended by his collaborators, representatives of the university and his family, van der Vleuten gave a short lecture (his last official lecture) entitled Beyond the evidence. I would like to share some thoughts on what was said there, which the interested reader can find by following the link given below [¹].

Van der Vleuten presented this lecture as a complement to the inaugural lecture he gave when he became full professor at Maastricht University in 1996, entitled Beyond intuition [²]. In it, among other things, he said that his new colleagues at the faculty he was joining, all clinicians and biomedical researchers, shared his same academic values, which reassured him and made him feel at ease. However, he quickly noticed something rather odd: the researchers' or clinicians' academic attitudes seemed to change when discussing educational issues. Critical evaluation and scientific judgement were then quickly replaced by personal experiences and beliefs, and sometimes by traditional values and dogmas. Although medical teachers are trained to make clinical decisions based on the available evidence, when they approached their teaching tasks they seemed to abandon all critical thinking about what works and what does not, and relied more on tradition and intuition.

This was somehow reiterating what Georges Miller had stated long before, namely, that the decisions teachers have to make when performing their teaching duties must be based on scientific evidence, and that medical education must be considered a field of knowledge like any other, with its own body of doctrine and the need for research in order to generate expert knowledge that can be applied to the improvement of educational practice.

Therefore, van der Vleuten considered that the mission of his academic life would be to generate scientific evidence in medical education, especially in certain fields within it. Evidence that he has achieved this in an important way are his numerous academic research papers, review articles and other publications, in which he describes the scientific evidence of certain approaches, such as problem-based learning, or the use of different assessment tools and, more recently, programmatic assessment.

However, in his retirement talk, Beyond the evidence, van der Vleuten asks himself whether evidence is enough to make progress in the field of medical education; whether, once the scientific validity of a given educational approach has been demonstrated, this is sufficient for its successful implementation in a given context. And here his answer is very clear: experience shows that the evidence is not convincing enough to make educational changes. Evidence is not enough. For the successful implementation of a given teaching innovation, the fact that its scientific validity has been demonstrated is not enough. There are two other very important aspects to consider: the cultural context of the institution where the innovation is to be carried out and the people involved in the change, that is, the teaching staff, who often display great resistance to change. Teachers have their own conceptions of learning, which are often wrong, and this makes them very reluctant to introduce changes.

How many times, he asked, when an attempt has been made to implement an innovative strategy in medical education with all the scientific evidence supporting its usefulness, has this implementation failed and could not be carried out because the cultural context in which it was to be introduced or the teachers' own culture, that is, their will to carry it out, failed? Therefore, in addition to evidence, the institutions and their members (the teachers) are key to success.

Van der Vleuten proposes two measures as essential for success: it is necessary to generate leadership among teachers and to accomplish the early involvement of all stakeholders, that is to say, leadership and critical mass. To achieve this, he insists on the need to establish training programmes in medical education for teachers, even on a compulsory basis, as in the Netherlands, for anyone wishing to become a university teacher or through master's programmes in medical education. It is the only way to change the culture of teachers so that they can implement evidence-based educational innovations.

In our context, we should be able to internalise the fact that medical education is an area of scientific knowledge like any other, officially acknowledge it as such, and at least try to offer more training opportunities in health sciences education programmes, which are scarce in our country, to facilitate and, above all, prioritise teachers' participation in them in order to generate leadership and a critical mass of teachers who are willing to change.

Medical education units or departments in medical schools, which are still very rare in our setting or not sufficiently developed and in many cases are dedicated to merely organisational teaching tasks, could be a good tool to begin to create this much-needed culture of change so that teaching experiences with sufficient scientific evidence can be successfully implemented.