Qualitative Research in the RIME Community: Critical Reflections and Future Directions*

This Thing We Call “Qualitative Research” Happily, the RIME community has moved beyond the (tiresome) debate about whether qualitative research is as “good” or as “valuable” as quantitative research. We now take the view, most of us, that qualitative research presents a different way of exploring a different set of questions than those accommodated in quantitative studies.1 This progress has been good for medical education research, encouraging the exploration of such social and human issues as professionalism, physician wellness, and team relations. It has also been good for qualitative research, which is proliferating in the context of its access to research funding, its growing community of graduate students, and its increasing appearance in peer-reviewed journals in our domain. The qualitative studies in this year’s RIME supplement demonstrate this success. However, my purpose in this wrap-up is to talk more broadly; not about the qualitative research reported at this year’s meeting, but about the discourse of qualitative research in the RIME community at large. In the process of getting qualitative research recognized, of achieving this acceptance of difference, a particular sort of qualitative research has materialized in our RIME community. This is sensible: in the many diverse disciplines in which it is practiced, qualitative research takes on the values and goals of its community of use. We might say that there are many discourses of qualitative research: for instance, in anthropology, the discourse is one of studying a culture’s lived experience by establishing intensive relationships between researcher and participant.2 In women’s studies, the discourse is one of exploring the nature of gendered lives towards revealing and challenging the politics of power in social situations.3 While these are simplifications, they point to a key question: what is our discourse of qualitative research in medical education? This brief paper will sketch two emphases in this discourse, towards a consideration of how we have constructed qualitative research in medical education, what that construction “selects, reflects, and deflects,”4 and the potential of alternative constructions as we take our work forward. Qualitative Research as a “Set of Tools” The term qualitative research is commonly used in our research community to signify the main methodological tools associated with the paradigm: observations and interviews. Authors report having used a qualitative method, done a qualitative interview study, or conducted qualitative analysis. This usage reflects an approach to qualitative research that is problematic in two ways. First, qualitative research is an umbrella category under which so many items fit that the category is diluted almost to the point of meaninglessness. Sociology of science, bioethics, feminist critical research, community-based action research—all of these and more fall into this category. Interestingly, I never called myself (or was referred to as) a qualitative researcher before taking up residence in the domain of medical education. In the humanities, where I trained, I had never heard this phrase. I am a rhetorician; I investigate the ways that language works in health professional education settings. This label characterizes the meanings I set out to create with my research; the tools of observation and interview are simply that—tools. These data-collection tools do not define qualitative research: many interview studies, for example, employ a quantitative approach to data analysis, counting the occurrence of content instances. So, while we emphasize the tools when we teach qualitative research, the tools themselves are not the essence of the qualitative paradigm. We need to do more than teach people how to use the tools; we need to teach them the epistemological or disciplinary purposes to which you put those tools. Which brings me to the second problematic issue: the focus on tools deflects attention not only from the meaningful diversity of approaches that employ qualitative tools in their knowledge making, but also from the orientation of that knowledge making. By orientation I mean, what kind of knowledge are the researchers setting out to make? What are their views on knowledge, their epistemology? Are they conducting the study from an ethnographic, a critical theory, or a case study approach? These dimensions matter much more than the methodological tools, because they shape the way the research question is asked. I can use interviews to study how novices interpret the banter on teaching teams, but how I frame that topic and the nature of the data I collect will vary enormously depending on my approach (e.g., grounded theory or phenomenology), my discipline (e.g., rhetoric or medical anthropology), and my epistemological starting point (e.g., social constructivism or positivism). In a recent workshop, a participant with some experience doing qualitative research asked me, “Why does it matter if we don’t bother with an approach? What are we missing?” My answer was that we are missing the positioning that sets us up for meaningful theorizing about what we discover. The call for more theory has become a common refrain in the medical education research community,5 one which we have heard in past RIME wrap-ups. The emphasis on qualitative tools rather than disciplines, epistemologies, and approaches may be one important factor in perpetuating this situation. Qualitative Research as Hybridization The way qualitative research has been enacted in medical education has been strongly shaped by the traditional rules of this scientific domain, with its emphasis on sample sizes, applied outcomes, and reliability of analyses. Those of us who have been here any length of time have contributed to this hybridization of qualitative research. In fact, many of us, me included, have capitalized on the rhetorical persuasiveness of crafting our research using principles adopted from the quantitative landscape. I have even devoted much mentoring energy to teaching my graduate students how to do this well and convincingly, how to compromise just enough to make it palatable to the broader RIME community while still doing meaningful qualitative work. We can view this positively, as a sort of knowledge-translation effort: qualitative research has had to learn to speak the language of medical education—traditionally a quantitative language infused with experimental values embodied in terms like reliability and generalizability. If we don’t wish to speak in a vacuum, we need to be able to tell the story of our qualitative work in a way that this audience can “hear” it, and engage with us about it. But language, as I’ve been known to say, is not only descriptive: we construct as well as describe through the language choices we make. And the situation of qualitative research in a medical education discourse community has had implications for how we have constructed and enacted the paradigm here. I would go so far as to say that, in hindsight, the process of hybridization has limited our ability to use qualitative methods to their full advantage. Hybridization has produced three main problems: (1) “thin” descriptions of surface trends resulting from sample sizes that are too large for close exploration of personal experience, (2) an attitude of impatience regarding data collection, resulting in a reliance on an overly discrete notion of research “sites” and on “high-yield” methods such as survey and focus group, and (3) a drive towards broadly applicable outcomes, resulting in analytical processes that focus on objectivity, norms, and group consensus, rather than revelations and startling distinctions. Seeing Past Current Practice Why might it be important for medical education researchers to care, at this point in time, about privileging close exploration of personal experience, cultivating patience in data collection, and emphasizing startling results that belie broad applicability? Well, one reason is the growing recognition of the individualized nature of patient-care trajectories and novice socialization experiences, and the understanding that deep consideration of something unique can, at a different level, inform our appreciation of patient and novice experience generally. Another reason is the increasing complexity of education and health settings, in which learning and care delivery are distributed, disjointed, and lacking a central, controlling force. Sophisticated understanding of such complexity is only possible through lengthy and distributed data collection and analytical approaches that do not elide the unexpected and unusual, that do not jump so efficiently from messy transcripts and fieldnotes to nicely organized thematic categories. Finally, both increasing complexity and the disjointed, individualized nature of experience in a complex system make subjectivity a critical and necessary analytical component. Consciously and systematically reported, subjective interpretation of experience can offer new insights that would, in our current analytical processes, be diluted or distorted in the push for group consensus (e.g., represented by reliability coefficients at the extreme). What do I mean by this? What is beyond the boundaries? Revive the N-of-1. Just like the clinical case that reports distinctive patient experiences and clinical conditions, there is surely room for close analysis of unique learner and teacher experiences that speak to critical issues in education. For instance, there may be benefit to an ethnographic study of a single student over the course of her residency as she grapples with and evolves her understanding of professionalism. Be patient. Bona fide understanding of a culture takes time, a great deal of time. Yet our scholarship takes place in the context of promotional expectations and submission deadlines, such that research is not a leisurely experience. To both accommodate and challenge this academic culture, we need to balance our research programs by having both impatient studies and patient ones. Realities of academic productivity will not go away, but some space could be made in the domain for ethnography-the-anthropology-way, with the benefits of multilayered insight and longstanding researcher/participant relationships that come from that discipline. Be alert to the benefits of the unique. I mean this on two levels: both the benefits of understanding the single experience, and the benefits of promoting subjective reflection and the analysis-by-one. Many other disciplines in the humanities have long embraced the insights that come from a single perspective—we, too, may have much to gain by not beating innovation out of the analysis process in our inexorable march towards group consensus. Conclusion Now that qualitative research has gained a firm legitimacy in our community, it is time to reflect on the discourse of qualitative research that got us here and to critique our cultural expectations about how it should be done. In preparing to speak to the issue of qualitative research for the RIME wrap-up last year, I confronted the reality that, although qualitative research has become well-positioned in our community, with awards, funding, and publication, the process of cultivating that success has constrained the way we do qualitative research here. In my view, two emphases in our current discourse need conscious attention and critique. First, the emphasis on qualitative research as tools limits the richness of our work. Positioning research within theory, discipline, and epistemology is essential if we are going to build knowledge, not just describe thematic categories. Second, the hybridization we have come to accept as the standard for qualitative research in the RIME community requires reflection, for it is a socially constructed standard that does not represent the full potential of the qualitative paradigm. My hope for the next decade of qualitative research at RIME is for scholarship that pushes the limits of our current discourse, that tackles knowledge-making not at the level of qualitative tools, but at the level of qualitative approaches and wide-ranging epistemologies.

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