LAUSR

The notion of quality lies at the heart of many local, national and international initiatives that consume considerable resources, including time and money. Use of the term can be reckless, however, given that it still eludes common and agreed definition. At times, an adjective is assumed, so that ‘quality education’ seems to mean ‘good quality education’. Or we turn the simple noun into a compound noun, for example, ‘quality improvement’ or ‘quality management’, meaning the thing that is done to quality. None of these usages actually tells us what ‘quality’ is when applied to education. The term implies many characteristics, many desirable qualities, but how do we make a judgement of what is good against this uncertain background? The papers included in this year's ‘State of the Science’ issue of Medical Education show that ‘quality’ implies different things in different contexts; further, they reveal that it is applied differently to many different aspects of education and performance. Grant and Grant, for example, argue that acquiring a generalisable evidence base as a means to define quality is an implausible aspiration. Singh and Meeks offer a more particular perspective by pointing out that global standards for medical education fail to address the inclusion of disabled people. Together, these papers suggest that treating such standards as a definition of quality may actually reinforce a lack of appropriate quality. Other papers in this issue focus on application of the concept of quality in ways that further suggest plasticity of terminology and variety in how issues related to ‘quality’ are realised. Jamieson, for example, highlights that ‘quality improvement’ is a contested term, while Amaral and Norcini examine the tensions, or contradictions, inherent in formal accreditation processes. They outline variability of context, purpose, processes and outcomes, the changing landscape in this area and the lack of evidence hazarded by ‘many confounding variables’. Such evidential and contextual problems pose a real challenge for our field and its efforts towards quality improvement, given that globalisation of accreditation, particularly when linked to the migratory movement of doctors, has recently been promoted on that basis. In that regard, Rashid examines the history of changing political, social, philosophical and power-based perspectives that have resulted in quality arguments supporting the loss of doctors from the global south to the global north. More generally, the papers amassed here highlight that the concept of globalisation in medical education almost invariably reinforces the dominance of the global north by emphasising the overpowering influence of medical education imperialism that emanates from the empirically unsupported idea that ‘metropolitan West is best’. Dominant ideas about quality itself tend to come from the global north, while most medical schools are in the global south. Through the thorough and thoughtful scholarship contained in this issue, we hope that readers will be better positioned to situate definitions and explorations of quality within their own context in a manner that enables challenge to this influence, moving medical education away from a unipolar world in which any one power can exert itself with minimal constraint. If globalisation is problematic, after all, so are attempts to understand and improve quality in very specific areas. Even in the well-researched field of clinical reasoning, Mamede and Schmidt show that myriad variables impinge on the formulation of unqualified claims. Samarasekera et al demonstrate that the concept of Received: 14 October 2022 Accepted: 18 October 2022