Picking Up Where the Authors Left Off: Reading Research in Medical Education

Reading is … an act of resistance in a landscape of distraction … it returns us to a reckoning with time. —David Ulin1 Research is a scientific endeavor that aims to create knowledge by asking relevant questions, using rigorous approaches, and formulating sound conclusions.2–5 These activities ideally culminate in the publication of a manuscript. Conducting rigorous research, communicating the findings in writing, and navigating peer review are often herculean tasks, and the authors of the manuscripts selected for this year’s Research in Medical Education (RIME) supplement should be congratulated for their accomplishments. As writers, we have all experienced that sigh of relief when our work is accepted—allowing us to cross another item off our “to do” list and move on to the next project. For authors, publication can feel like completion, eliciting a sense of satisfaction and closure. For readers, however, publication is only the beginning. While the effort invested in research writing and reviewing is substantial, resulting manuscripts cannot create knowledge alone: for human knowledge requires a “knower,” and research writing (arguably) requires a reader.6,7 Reading and writing, therefore, are inextricably connected partners in the same communicative dance.8,9 The dance is social because reading—like writing—involves entering a conversation,10 the text providing a space for authors and readers to meet and engage one another’s perspectives.11 The dance is also rhetorical because reading—like writing—involves persuasion. Writers strive to convince readers of the relevance and rigor of their work and motivate readers to change what they do or how they think based on the results. Readers, in turn, open themselves up to the possibility of persuasion and influence as they meaningfully engage with the authors’ words and ideas.9 As David Bartholomae, Anthony Petrosky, and Stacey Waite write in the introduction to their book Ways of Reading: Reading involves a fair measure of push and shove. You make your mark on a text, and it makes its mark on you…. Reading is not simply a matter of hanging back and waiting for a piece, or its author, to tell you what the writing has to say. In fact, one of the difficult things about reading is that the pages before you will begin to speak only when you begin to speak….12 Readers, therefore, are not passive consumers of research knowledge but active contributors to the knowledge creation process.13 While readers may be less visible to researchers than reviewers and editors, they are perhaps even more important.14 Good writers have these readers in mind throughout the research process as they are refining their research question; choosing a research approach; and maximizing the relevance, reach, and impact of their work.15 Prior RIME Forewords have explored research topics (including research questions, rigor, and relevance) from the standpoint of writers, reviewers, and RIME Program Planning Committee members.2–5,16,17 In this year’s Foreword, we (the current, incoming, and immediate past cochairs of the RIME Program Planning Committee) aim to “continue the conversation” by examining these topics from the perspective of readers. Reading as Asking Good Questions If research writing can be understood as entering a conversation,10 then research reading can be understood as being a good conversation partner. Lively conversations often begin with good questions—a topic the 2019 RIME Foreword explored in relation to research.4 Research questions are consequential because they focus and direct the study design and affect the relevance of the results: quality research relies on good questions. Readers also bring questions to the conversation, and these questions are likewise consequential: consequential for authors because they determine if and by whom their research is read; consequential for us, as readers, because the questions we have in mind as we read a research paper affect the knowledge we create; and consequential for others (such as learners, patients, or peers) who may be affected by what we choose to read and how we think, believe, and act as a result. Our questions as readers differ in terms of when we ask them, how we ask them, and why we ask them. Sometimes we formulate a question before we read. Other times we read because we are curious, sensing a question we cannot yet fully articulate. The act of reading can also uncover questions we did not know we had or generate new questions that guide what we read next—a clear demonstration of the importance of readers to how research literature is shaped and understood. Regardless of when and how they appear, reader questions act as radars for relevance, catalysts of curiosity, and windows to worldview. Our questions as readers can also provide onramps to more rigorous reading, which then, in turn, often leads to deeper and more probing questions. What, then, makes for good reader questions? The answer depends on our reason for reading.18 If we consider knowledge creation as the objective, then rigorous readers will ask at least 5 types of questions (Table 1), organized by their function: (1) rhetorical questions to test the logic, credibility, and emotional impact of a persuasive argument, as outlined in a research paper19(p5); (2) philosophical questions to uncover, examine, and potentially alter our deeper reasons for belief20(p7–9),21; (3) critical questions to unmask systems of oppression and bring marginalized voices to the forefront17,22; (4) postcritical questions to unveil new horizons of possibility enabled by the research or our experience of reading it23,24(p32); and (5) practical questions to identify day-to-day habits, practices, and relationships that will help us use research knowledge to live well in the world.20(p25–28) By asking and answering these sorts of questions, readers can actively contribute to knowledge creation.Table 1: Examples of Reader Questions, Organized by Their FunctionReading With Rigor Good conversationalists do not just ask questions. They also listen carefully, respond thoughtfully, and build on what others have said. Reading well—like writing well—involves analogous conversational acts. Reading, therefore, can be understood as both a form of listening (attending to what the text is trying to say) and speaking (asking and answering questions, adding insights). Together, these acts enable sensemaking (creating meaning from what we read) and contribute to rigorous reading. Reading as listening What does it mean to listen while reading? We suggest that good readers—like good listeners—are active and attentive. Good readers underline sentences, outline the argument, summarize sections, and mark up the margins. Good readers attend to verbal cues—reading with the text by exploring its terrain and keeping company with its ideas.25 Good readers also attend to nonverbal cues—reading behind, between, and beyond the words on the page by noticing how things are put; what is left out; and what is accepted, assumed, or subverted.11(p22) Good readers are empathic, working to say, “I understand” with reasonable certainty before saying, “I agree” or “I disagree.”26(p141) Reading as listening requires patience, humility, and tolerance: patience to accept the tension between making judgments and suspending judgment as the authors’ reasoning and research argument unfold11(p101); humility to acknowledge the limits of what we can know and prove; and tolerance to step out of our “comfort zone” and listen to new ideas that may be confusing or challenging, unsettling or unfamiliar, objectionable or uninteresting.27(p11) Reading to understand (like listening to understand) does not grant legitimacy; it grants humanity—and preserves our own.28(p157) This sort of listening requires courage—both the courage of conviction27(p85–86) and the courage to risk being changed,28(p143) which always “exacts some cost in comfort and the security of being ‘right.’”11(p103) As Mark Edmundson asks in the book Why Read, “What good is this power of critical thought if you do not yourself believe something and are not open to having these beliefs modified?”29(p43) Reading as sensemaking Rigorous reading goes beyond listening in that it also requires intentional efforts to make sense of what we read. This sort of reading has variably been described as active reading,30 close reading,31 deep reading,32 reflective reading,33 critical reading,34 analytical reading,26 and rhetorical reading.9 While areas of emphasis differ, these forms of reading all cast readers as active creators of knowledge—as agents who produce or coproduce (versus simply unravel) meaning from a text.24(p12) This process of knowledge creation unfolds through acts of interpretation, critique, and synthesis.9 Acts of interpretation involve the dual tasks of determining the meaning and significance of a study (as conveyed by the authors) and discerning the assumptions and sources of knowledge upon which the research rests.9,17 Reading is where the paradigm of the reader meets the paradigm of the researcher, allowing us to examine our own beliefs alongside those of others.5,9 Choosing to accept, question, or resist the terms of a text involves discerning its premises and examining its epistemé (who has been “allowed” to contribute to knowledge creation and how). Prior RIME Forewords,5,17 RIME commentaries,22,35 and other resources36 can assist readers with distinguishing research paradigms and considering how a given piece highlights or shadows particular points of view. Acts of critique involve evaluating if and to what degree study results are worth believing9—or at least worth provisionally incorporating into our “store of hypotheses about how life is to be understood.”32(p41) The process of thoughtful critique involves conversing not only with the authors but also with ourselves—examining the text in light of our prior knowledge, personal experiences, emotional reactions, social conventions, and moral intuitions. It also involves credibility judgments. Like learners appraising feedback,37 the criteria we use to determine if, what, and whom to believe as readers are complex and personal9—rooted in the particularities of our situations, contexts, and journeys. Acts of synthesis involve integrating what we read with other information sources, including those derived from our own experiences, and combining them into a coherent whole.9 While writers aspire to present their research in ways that will connect with multiple readers (a “target audience”), as readers, we must sift through multiple sources of information to find ideas that connect with us—our knowledge, our beliefs, and our priorities. Syntopic reading (a form of reading for synthesis) seeks to do this deliberately by reading about the same topic from multiple sources or perspectives.26(p326–327) Reading about different, seemingly unrelated topics is another generative practice that creates opportunities for new connections, analogies, and insights.38(p99–119) As scholar and literary critic Rita Felski writes, Reading … is a matter of attaching, collating, negotiating, assembling—of forging links between things that were previously unconnected … of creating something new in which the reader is as decisive as that of the text…. Reading is not simply a matter of deciphering content but involves taking on and testing out new perceptual possibilities.24(p173–174) These acts of synthesis extend the research conversation and help bridge research to practice as we incorporate new knowledge into the mental models we use to navigate personal and professional life. They also push knowledge generation beyond what the authors have written by elaborating details, nuances, or considerations that are not present in the prose and using these elaborations to support, contest, or extend the authors’ claims. Reading for Relevance In an applied field like medical education, the goal of research is often to create knowledge that is useful for practice—for making education work and making it work better in the everyday practice of teaching.5,21 The 2018 RIME Foreword explored the role of relevance in research and outlined steps researchers can take to enhance the relevance of their work.3 While there is much that researchers can and should do, readers are also uniquely positioned to help realize relevance. In other words, it is often readers who are situated to mobilize and operationalize research in practice—to make sense of the world by making something of the world.39(p24) For readers, relevance is a point of entrance, a point of reference, and a point of departure. Relevance is a point of entrance because it directs our attention and determines if and what we read. We skim titles and abstracts and tables of contents for articles that relate to who we are and what we do because the vastness of medical education research exceeds what is feasible for us to read. When something piques our interest, we linger longer, listen closer, and dive deeper. Relevance motivates us to invest the time and energy required to ask thoughtful questions (Table 1) and read with more rigor. Relevance is a point of reference because it informs the questions we ask as we read and the criteria we use as we interpret, evaluate, and synthesize knowledge. Relevance as a point of reference reveals itself in the familiar questions, “So what?” and “Who cares?”—questions that are as important for readers as they are for researchers. The latter question in particular reminds us that reading for relevance involves considering not only our own perspectives but also the perspectives of others, including those who may never read the research that is nevertheless relevant to their experience.14 Relevance is a point of departure because it motivates us to act (or not) on what we read—for knowledge is not only a mental representation of the world but also a tool for operating in it.16,40 Operating in the world requires attending to practical concerns: affordances and constraints, affordability and acceptability, sufficiency, and defensibility.14 As readers, we can bring these sorts of issues to bear on the research we read and test the utility of research findings in the many and varied contexts we represent. Relevance also motivates us to share research with others by forwarding an article to a friend; convening a journal club; or contributing letters, commentaries, podcasts, videos, tweets, and research of our own. Such activities can help bring new voices into the conversation, further expanding and enriching the knowledge-creation process. Relevance as a point of departure reminds us that “to know is not enough”13—for action does not automatically follow from reflection, nor transformation from information.39(p67) Texts cannot influence the world by themselves.24(p172) The relevance of medical education research, therefore, derives not just from its usefulness but from its use—for example, from readers and other actors using research to resolve problems of practice,5 dismantle systems of oppression,17 pursue new horizons of possibility,23,24 and live wisely in the world.20 Reading for relevance challenges us to knead worthy research knowledge into our hearts, minds, and lives so we can become active partners in realizing these aspirations. When is Rigorous Reading Justified? Many of our “conversations” as readers are superficial and brief—akin to quick hallway conversations or chit-chat about the weather. Some attempts at reading devolve into distraction or frustration. A few blossom into more lively banter or a sprightly give and take. The best last longer, wander further, and go deeper—taking us to new places, giving us novel ideas or new perspectives, and leaving us wanting more. This sort of rigorous reading is valuable but also effortful. The very real constraints of time and attention require judgments about when this effort is justified. After all, some texts are “to be tasted, others to be swallowed, and some few to be chewed and digested.”41 As readers, we often rely on heuristics to inform these judgments—quickly appraising relevance and credibility from topics or titles, an author or abstract, a trusted source, or trending tweets. These heuristics can be helpful, but—like all heuristics—they are shortcuts that can cause us to miss important content and cues. The solution is not to always read slowly and effortfully, but rather—like experts performing surgery—to slow down when we should.42,43 As scholar, teacher, and advocate Maryanne Wolf puts it in her book, Reader Come Home, “reading quickly until we are conscious of the thoughts to comprehend, the beauty to appreciate, the questions to remember, and—when fortunate—the insights to unfold.”32(p193) Reading in this way involves an embodied attentiveness that is effective as well as analytical,24(p188–191) attuned to textual details that resonate with our experiences, challenge our conventions, capture our curiosity, or inspire our imagination. Conclusions Readers, writers, and texts form a triangle of communication—a conversational nidus for the social and rhetorical work of knowledge creation. Having already acknowledged the important work of authors, we (the authors of this Foreword) conclude by dedicating this year’s RIME supplement to you, our readers. We are confident you will find 1 or more of the manuscripts worthy of rigorous reading and invite you to contribute to the conversation by engaging with the authors’ work. We hope you will enjoy the subset of papers selected for podcasts and look forward to connecting with many of you at the upcoming Learn-Serve-Lead conference. Your time and attention are an important part of the RIME conversation, and you, too, should be congratulated for your accomplishments! Of course, medical education research does not occur in a vacuum. It is made possible by the hard work of many people. As current, past, and incoming cochairs of the RIME Program Planning Committee, we want to thank the reviewers, committee members, mentees, and staff members from the Association of American Medical Colleges for helping make RIME rigorous, relevant, and (hopefully!) relatable. Together, you embody RIME’s values of excellence, connection, and growth.44

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