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Invited Commentaries: Philosophy of Science

Being Edgy in Health Professions Education: Concluding the Philosophy of Science Series

MacLeod, Anna PhD; Ellaway, Rachel H. PhD; Paradis, Elise PhD; Park, Yoon Soo PhD; Young, Meredith PhD; Varpio, Lara PhD

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doi: 10.1097/ACM.0000000000003250
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Abstract

Although individual scholars in health professions education (HPE) are trained in a multitude of disciplinary traditions, they must collaborate to push the boundaries of our knowledge. To understand and appreciate the scholarly traditions of our collaborators, HPE researchers need to reflect on and justify the foundational concepts, premises, and theories that underpin the knowledge generated within different paradigms and fields of inquiry. In other words, it is precisely the bringing together of different research traditions that gives rise to what has been called the multidisciplinary edge effect.1

The power of collaborative research across paradigmatic boundaries lies, at least in part, in the fact that multidisciplinary research requires scholars to contend with an unsettling fact: There is nothing natural about how we engage in research. As HPE investigators, we are steeped in the ontologies, epistemologies, axiologies, and methodologies of the paradigms within which we have been trained. The ways in which we engage in scientific research reflect years of enculturation to the norms and ideologies of our disciplines. These principles shape who we are as scholars, how we see the world, and how we explore it. Multidisciplinary collaboration requires us to pause and think about what we might learn if we embraced other paradigmatic principles and approaches as valid and important; took on the challenge of conceiving of knowledge, methods, and values in new and unfamiliar ways; and took advantage of opportunities to find common ground.

Throughout the Philosophy of Science series of Invited Commentaries,2–8 we provided readers with the tools to begin considering the contributions of 7 different research paradigms by offering concise and accessible overviews of positivism, postpositivism, critical theory, constructionism, sociomaterialism, postmodernism, and critical realism. In doing so, we offered insights about the ontological, epistemological, axiological, and methodological foundations of each paradigm. We should stress that this is not a comprehensive list of research paradigms; instead, it is a collection of the paradigms frequently used in modern HPE research and those that we believe are gaining traction in our field. We also included an overview of the concepts of theory, theoretical framework, and conceptual framework9 with a goal of elucidating these frequently used, but often misunderstood, concepts.

In offering this set of primers, our intent was not for these Invited Commentaries to serve as the ultimate resource on each paradigm we have covered. Within each paradigm, there is ongoing scholarly conversation and rigorous debate about ontological and epistemological foundations, axiological principles, and methodological developments. We also note the broader philosophical debate regarding whether separate paradigms exist or whether there is instead a collection or even repertoire of ontological, epistemological, axiological, and methodological options available to scholars.10 Rather than delving into these broader deliberations, our Philosophy of Science series was designed to make visible some of the foundational elements of key paradigms informing HPE—including the ways we conceptualize knowledge, the relationship between knowing and known, the values underpinning these ideas and practices, and strategies for collecting data.

Our recurring use of the case of Lee (Box 1) served as an example of the complexity of the philosophy of science in the context of HPE. Throughout the series, each article presented an example of how this case might be investigated from a particular paradigmatic perspective. The same case, when viewed from different perspectives, can inspire different types of research questions, different research objectives, different study designs, and different understandings of the scenario itself. Ranging from a positivist controlled experiment that tests hypotheses to investigate the unexpected performance of the medication, to a postmodern exploration of the power dynamics at play in a trainee–attending supervisory relationship, to a sociomaterial investigation of the productive role of the medication vial, we can see that there is no shortage of questions to be asked or study objectives to be addressed. With methods ranging from a postpositivist 2-armed experiment investigating whether disclosing an error influences judgment about competence to a constructionist analysis of audio diary reflections on what it feels like to be part of a medical error, the actual tools researchers could use to interpret the case are varied and complex, allowing for nuanced insights to emerge. In short, the possibilities for investigating issues relevant to HPE are limited only by our imaginations, or, perhaps more accurately, by our abilities to see, and think, within and outside of our home paradigms.

Box 1

Sample Casea

Lee was a resident assigned to monitor a postop patient. The patient had a periodically low respiratory rate and lower-than-normal pulse and blood pressure. Narcan was ordered on an “as needed” basis to be given in doses of 0.2 mg intravenously. In checking the patient’s vitals, Lee decided it was time to administer an intravenous (IV) dose of Narcan.

Once Lee injected the vial of Narcan into the IV port, Lee noticed it was labeled “2 milligrams per 1 milliliter (ml)”—the entire vial should not have been injected. Feeling panicky, Lee reported the mistake to an attending and rushed back to the patient’s side to monitor the vital signs. Lee was surprised to find that the patient’s vitals had come up to normal rates, and the patient was actually much more alert. When Lee reported this change to the attending surgeon and anesthesiologist, they told Lee to continue to monitor the patient closely, remarking that it may have been just what the patient needed.

Lee felt hugely relieved, but was still overwhelmed and very upset. In most cases, giving 10 times a normal dose of any medication could have led to extremely serious consequences and even death. Still, Lee managed to remain outwardly composed, and took the time to complete an incident report. At the end of the day, when Lee finally sat down to rest, the incident played over and over again. Lee did not sleep.

aThis sample case is used throughout the Philosophy of Science Invited Commentaries to illustrate each research paradigm.

A Point of Clarification: Paradigms, Methodologies, and Methods

Given that this is a review of key points relevant to the philosophies of science at play in HPE scholarship, we return to the relationship between paradigms, methodologies, and methods. Paradigms are the philosophical axioms and assumptions that shape a particular approach to inquiry and that are shared within a disciplinary discourse. Methodologies are the structural approaches to conducting acts of inquiry. Methods are the specific techniques and processes of enacting inquiry. For example, positivism is a paradigm, a randomized controlled trial is a methodology, and its various data gathering and analysis tools are its methods.

As the content of this journal clearly shows, there is no shortage of methods and methodologies that can be used in HPE research. As the field continues to evolve, we will undoubtedly see even more innovation with respect to the tools and approaches we use to gather and analyze data. In addition to the methodologies and methods highlighted in the various contributions of the Philosophy of Science series, high-quality HPE research is also happening using methodologies and methods we did not explicitly address, including literature reviews (a set of methodologies relying on literature as a data source), expert consensus methods (a set of methods with the goal of building consensus statements or best practices), big data (an approach to data collection where an entire population is the sample of interest), and artificial intelligence (a set of methods for data optimization), to name a few.

Rather than attempting to describe the wide range of methods a scholar of HPE might use, we want to make clear that specific methods do not belong to or represent only one particular paradigm. Experiments are not necessarily the property of positivists. Observational work does not belong only to sociomaterialists. A paradigm may have many methodologies, a methodology may employ many methods, methodologies may be used in different paradigms, and methods may be mobilized in different methodologies (see Figure 1).

Figure 1
Figure 1:
The relationship between paradigms, methodologies, and methods.

While it might be tempting to classify methods as emblematic of a particular paradigm, we hope this series has made clear that it is not only how research is conducted that matters. Indeed, the philosophical positions underpinning the research project are equally worthy of our attention.

To illustrate this point, let’s consider literature reviews. Depending on the paradigm and/or methodology, the type of literature to be included can vary; it may be qualitative, quantitative, or some mixture thereof, and it may rely exclusively on peer-reviewed journal articles or it might include other “gray” sources. What the researchers consider data and how they consider those data reflect the different methodological approaches to literature-based studies, ranging from meta-analyses to narrative analyses. Meta-analyses—which focus on statistically synthesizing effects from multiple scientific studies—are generally aligned with positivist perspectives. Scoping reviews, in contrast, generally aim to map the literature to build an understanding, which is closely connected with constructionism. Realist reviews aim to understand the impact and mechanisms of an intervention and are exemplary of the beliefs of the realist paradigm.

A similar example can be made using the idea of big data. These user-generated data intend to build meaning from pattern recognition by analyzing very large data sets (derived via extrapolating from number of hits, tracking geographic location, etc.). These quantitative approaches are focused on deriving patterns and predicting behavior, which aligns with a positivist paradigm. However, there are recent examples of big data being used to make visible systematic inequities in health care access and delivery, aligning these approaches within a critical paradigm.

We could continue to provide examples of methods and methodologies that are mobilized differently depending on philosophical entry points and overall intent; however, the point we want to make is that a specific method or methodology is not indicative of a particular paradigmatic approach. Rather than focusing on the “how,” we encourage those with an interest in the philosophy of science to focus on the “why”?

Multidisciplinary Perspectives: Working Across Edges

That many scholars become embedded within a single research paradigm is understandable. Our paradigmatic home influences our identities as scholars, including what we read, the types of education that we consider, where and how we share our scholarship, and many other factors. These traditions can make it difficult to see the world of possibilities offered by other paradigms. Overreliance on certain methods, accompanied by an unexamined belief in their value or promise, may restrict our ability to think critically about complex issues and problems.11 As we describe in the introduction to this series,1 we believe that diverse perspectives and multidisciplinarity will help scholars address the various challenges faced by HPE.

Successful multidisciplinary collaboration may involve mixed methods research—approaches that rely on both quantitative and qualitative data to answer a question or explore a topic.11 In HPE research, the potential for mixed methods approaches is clear. Our ability to see the world is a product of our ontological, epistemological, axiological, and methodological principles—and this means that each paradigm has strengths, but also important blind spots. Mixed methods approaches have the potential to overcome this, combining the strengths of each paradigm12 to allow for more breadth, depth, and richness, and thus have the potential to yield more meaningful interpretation and application of findings.13

However, we must be wary of engaging in interdisciplinary and mixed methods research in uncritical, nonreflexive ways. In reaction to the rise in popularity of mixed methods approaches, there is a race to create elaborate templates and procedures for combining methods. While we appreciate this enthusiasm, we caution that, without sufficient consideration for how various methods relate to research problems and methodologies, mixed methods research is at risk of becoming a “techniques-driven enterprise that promises more than it can deliver.”11(p210) As the Philosophy of Science series articles describe, each research methodology, and its related methods, arise from specific philosophical roots. It is vitally important that these paradigmatic roots be considered and respected when mixing research methods. Aligning methods and methodology to the research question and context, and ensuring the philosophical foundations of the various strategies work together, will remain of central importance.

A Final Word

The practices of HPE are complex and our challenges are multifaceted. The multiple paradigms working in the realm of HPE research can take us outside our comfort zones. However, we believe our field benefits when we acknowledge this complexity and investigate HPE issues from multiple perspectives. Whether we choose to read a paper from a different paradigm than our own, consider a new perspective on a particular topic, or engage in a collaborative, multidisciplinary project, we hope the Philosophy of Science series piqued your interest regarding what it means to engage in HPE research based in an unfamiliar paradigm.

The ability to function and draw inspiration from other paradigms is a key benefit of engaging in a broader consideration of the philosophy of science in our field. For instance, when the edges of disciplines overlap—bringing together the perspectives of neurologists, sociologists, and everyone in between—we can address HPE’s most pressing issues from a position of creativity and innovation.

We do recognize, however, that cross-paradigmatic work is not easy. Working across the ontological, epistemological, axiological, and methodological assumptions of the various paradigms calls for deliberate reflexivity, openness, and a desire to learn deeply about, and from, an alternate perspective. We hope this series helps you to approach HPE research with an open mind and inspires you to approach your research with a new edge.

References

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