Educational potential of medical audit: observations from a study of small groups setting standards.

While the main thrust of medical audit has been towards improving clinical performance, there has been increasing recognition of its impact as a method of continuing medical education. Thus, the Royal College of Physicians stated that "education is the most useful product of audit,"' and the Royal College of Surgeons noted the educational importance of audit "for both seniors and juniors."' Furthermore, Batstone suggests that audit can be seen "as a process leading to improved clinical care by mechanisms which may be educational, operational, or both."' Coles agrees with these emphases but points out that education (by which he means learning) does not automatically occur just because people go through an audit cycle. Effective learning requires an appropriate and deliberately created set of conditions, among which group based strategies are increasingly important.4 As Scott and Marinker stated: "if medical audit is to become an integral part of clinical practice and practice management ... those who take part in it will need from time to time to constitute themselves into formal small groups."' The educational potential of group work has been recognised in medicine and higher education generally.6 ' For example, Hull argued that "the special characteristic of the small group is the opportunity it provides for members to examine their own attitudes and modes of thinking."' But the relation between group work and education is not straightforward. For instance, Hull is careful to point out that groups provide the opportunity for learning rather than a guarantee that learning is successful, and Coles warns that education in groups does not simply happen; it has to be organised.4 However, even when they are carefully planned, educational initiatives can sometimes fail to result in successful outcomes. As those with experience of working in a group can testify, group process is subject to many influences, not all benign. The aim of this article is to describe some of the characteristics and the functioning of groups involved in a standard setting process and to comment how the educational potential of collaborative audit is contingent on group processes. The first section describes the educational potential and identifies some of the process factors which may influence its realization. The second section draws on an observational study of groups setting standards and illustrates how problems arise in groups. The final section discusses the implications of the study's findings for the relation between groups, education, and audit.