Health professions education research benefits from the contributions of multiple fields and disciplines, ranging from engineering to kinesiology to sociology. However, these disciplines bring with them a range of different assumptions about the “objectivity” of science and appropriate ways of generating new knowledge. As a result, there are tensions between philosophies that understand knowledge to be stable and those that understand knowledge as more subjective or socially constructed. Understanding what these distinctions mean and how they impact your study design is critical so that the logic of your goal, theoretical framework, design, results and interpretations are philosophically aligned.
By the end of this chapter the learner should be able to:
- Describe the concept of epistemology
- Describe at least 3 epistemologies in health professions education
- Identify the epistemology with which they identify
Rayna (they/their) was always interested in science and wanted a career in healthcare. They cared deeply about research and improving healthcare. As a program director, Rayna encouraged a culture of inquiry and best practices in education. Their own interests in science inspired the creation of education rounds, so that faculty and trainees could share and explore new ideas in health professions education. For the department’s first event, Rayna invited a senior clinician educator to present research on competency-based medical education (CBME). At one point in the presentation, the speaker referred to the epistemologies behind most CBME research, and how those epistemologies change the kind of evidence the research produces.
Rayna was immediately thrown, as the obvious question that floated through her mind was: ‘what is an epistemology?’
The speaker kept going on and on about the importance of constructivist perspectives, but Rayna didn’t really feel like she had a clear understanding of what constructivism is – let alone what it looks like in a research study. And why did the speaker describe most approaches as positivist? But being the program director, this was a rather uncomfortable question to pose in front of everyone.
An Introduction to Philosophies of Science
Philosophies of science (1,2) are foundational to all research, although many people are exposed to science, research and the scientific method without a full appreciation of the different philosophies of science that underpin the different types of evidence they encounter. The dominant philosophy in science, indeed the oldest, is positivism. Positivism is defined as a view of the world where there is one truth to be discovered. The basis of positivism is empiricism, which prioritizes knowledge as only that which is observable and measurable.
The scientific method then is the ideal approach to uncover the one truth. The strict scientific method is often described as rigorous, and objective. The goal is to introduce objectivity into a study so that the experimenter does not unduly influence the results with their own biases. Many will be familiar with the concept of the randomized-control trial, as an example of good science in healthcare. This methodology is held at the highest standard of rigor because of the ability to manage all variables and isolate them within a controlled environment, free of irrelevant contexts. However, this has inappropriately been used as a standard against which to compare other methodologies. In material sciences, such as chemistry, a purely positivist perspective is manageable. There are known properties of chemical compounds and also known interactions with different environments; knowledge that was gained through carefully controlled studies. However, a pure positivist perspective is fraught with challenges as we consider the science of the mind, and education science. For example, consider the fluid state of knowing and doing the right thing (3).
Health professions trainees are capable of fully understanding and supporting the ideal behaviour in practice, but various factors will influence their decision to take action. These factors include the situational context and their own values, which may lead them to choose different actions for seemingly identical scenarios. It is impossible – and even undesirable – to try to control for all of these different known and unknown variables. To understand educational research from a positivist lens would be to assume that there is only one way to understand a problem and that highly controlled experiments are the path to finding out what it is.
While post-positivism is still committed to the pursuit of truth, but accepts that context, measurement error and individual differences create different outcomes, preventing us from ever really getting to a single truth (4). There is general acknowledgement that science is about uncovering generalizable principles, but that research is filtered through human perceptions and imperfect research methods and instruments. As a result, the job of the post-positivist is to get as close as possible to “truth” with an awareness that their efforts are fallible and their results will always be, at best, an approximation of that truth. Post-positivist researchers in HPE don’t seek to find “the Truth” of a problem; rather, they are looking for smaller truths that, together, form a more accurate picture of a problem. Approximating truth, though, is still the goal. They carefully select and control their methods to reduce bias as much as possible.
Interpretivism (5) and its close relative, constructivism, assert that knowledge and indeed reality, are not “out there” to be discovered. Rather, people (including researchers) actively interpret and construct their reality. In other words, interpretivist researchers tackle complicated problems and do not assume that “truth” exists independently of people’s interpretations. Constructivism adds that those interpretations are social in nature – individuals cannot independently interpret the world. They are always interacting with meanings generated by and with others, and these interactions form the basis of their own interpretations. HPE researchers coming from these perspectives assume that their research should seek to understand how meaning is constructed by participants, and how researchers are part of that meaning-making.
Finally, critical philosophies assume that all of our understandings of reality, and our constructions of the truth, are mediated by power. Similar to interpretivism, critical theorists assume that reality is constructed. However, they believe that our world is fundamentally shaped by power, wielded by individuals and organizations, and shaped over time by social, political, cultural, racial, and gender constructs (6). While power is an inevitable part of society, its current distribution is fundamentally unjust. Thus the primary unit of analysis for HPE researchers informed by a critical philosophy is power, and their goals are focussed on critique aimed at making change to enhance social justice.
The following table (Table 1.1.1) details a summary of dominant epistemologies in the health professions. Although listed here as somewhat discrete categories, it is possible for individual beliefs to vary based on context, such that even the same individual will align with different epistemologies at different times (4)
|Epistemology||Relevant Ontology||Impact on approach to research|
|Positivism||Reality, or truth, is knowable. There are generalizable principles that govern everything.||Knowledge describes reality for all. Knowledge can be captured and shared in objective and neutral ways. Promotes deductive reasoning from question, to constrained expectations and hypotheses to clear interpretations of outcomes. Replication of study results is often required to ensure sound science.|
|Post-positivism||Reality, or truth, is knowable. There are generalizable principles that govern everything. Unfortunately, because of the complexity of the human mind, and limitations of our methods, we will never really get to the truth.||Knowledge represents a parsimonious perspective of reality. A parsimonious perspective is one that should generalize to all (really most) situations. The idea being that the simplest explanation is best, even if it is not true for every situation. There is recognition that reality cannot be measured directly. However, hypotheses and expectations can be made clear, and the keen scientist should be open to the message held within the data. Replication of study results should always be sought.|
|Interpretivism||Reality and truth are not directly measurable. ‘Truths’ are malleable and may shift even from the perspective of the same person across time and context. ‘Truths’ may also be influenced by the researcher.||The data can reveal multiple truths to anyone who is listening closely enough.|
|Constructivism||Reality and truth are not directly measurable. ‘Truth’ are realized in the context of social interactions as our understanding of our own experiences is determined by out relation to others.||The data can reveal multiple truths to anyone who is listening closely enough. Indeed the apparent truth may be different depending on who is listening (i.e. conducting the analysis). Researchers should be transparent regarding their reflexivity. Replication of study results would never be expected or sought. Participant bias may be a finding, but not an element to control in the pursuit of meaning|
|Critical Theory||Reality and truth are not directly measurable. Our understanding of reality and truth change with shifts in organizations of power.||The data can reveal multiple truths to anyone listening closely enough. These interpretations will be influenced by power dynamics. The goal of critical theory research is to critique unjust power dynamics to improve equity.|
In summary, when debating, designing, conducting, analyzing or interpreting research goals and findings, consider the assumptions you are making along the way. Good research is based on an alignment between one’s epistemology and the chosen research methods. Critically, impactful research requires appropriate storytelling that presents findings that can translate across multiple epistemologies. If you are not sure you want to commit to one and only one epistemology, then approach your work with the following principles in hand:
- Objectivity – Objectivity is valued by positivists and post-positivists but research does not exist in a vacuum. All research is driven by subjective research interests, goals, and decisions. Even the most seemingly positivist basic science experiment may have subjectivity introduced by the study designers.
- Subjectivity – Inherently, subjectivity is not all bad but pretending that there is no room for subjectivity in your science is problematic. Being transparent about one’s perspectives and research goals leads to excellent science as the reader can use their own judgment in interpreting the research question and the results. Indeed the reader may also choose to replicate or build on the study using a different perspective, enhancing our overall knowledge of the phenomenon.
- Transparency – Consider how you can examine and communicate your perspective or subjective decisions within your research. Start by communicating them to yourself. Consider discussing them to colleagues. You may also want to attempt to communicate these beliefs through your writing. In any event, be reflexive and transparent about your decisions and the impact of your subjective experience on your own findings and those of other scientists. Exploring these concepts and questions can better prepare you to help others understand your work.
- Ethics – Good science is built on an ethical approach to design, recruitment, and analysis. Just as there are standards for ensuring the fair and ethical treatment of human and nonhuman participants, so too, being attentive to one’s perspectives and decisions ensures that the results are handled ethically. Regardless of whether you take a critical perspective, it is important to consider the power dynamics at play and the impact of your research on participants and communities. This section is discussed in much greater detail in Chapter 4-1.
Rayna was able to meet with a close colleague over coffee and discuss the issues after the rounds. The colleague shared a link to some interesting podcasts and reading materials to help Rayna explore these concepts independently. Importantly, Rayna begins to understand that this is a fundamental concept that she must work harder to incorporate into the beginning stages of our scientific process.
- Butts JB, Rich KL. Philosophies and theories for advanced nursing practice. Jones & Bartlett Publishers; 2013 Dec 26
- Varpio, Lara PhD; MacLeod, Anna PhD Philosophy of Science Series: Harnessing the Multidisciplinary Edge Effect by Exploring Paradigms, Ontologies, Epistemologies, Axiologies, and Methodologies, Academic Medicine: May 2020 – Volume 95 – Issue 5 – p 686-689 doi: 10.1097/ACM.0000000000003142
- Kahlke RM, McConnell MM, Wisener KM, Eva KW. The disconnect between knowing and doing in health professions education and practice. Advances in Health Sciences Education. 2020 Mar;25(1):227-40.
- McMurtry A. Relief for the exhausted post-positivist: New epistemological choices transcend positivism, relativism, and even post-positivism. Canadian medical education journal. 2020 Dec;11(6):e197.
- Bunniss S, Kelly DR. Research paradigms in medical education research. Medical education. 2010 Apr;44(4):358-66. https://doi.org/10.1111/j.1365-2923.2009.03611.x
- Paradis, E., Nimmon, L., Wondimagegn, D., & Whitehead, C. R. (2020). Critical Theory: Broadening Our Thinking to Explore the Structural Factors at Play in Health Professions Education. Academic Medicine, 95(6), 842–845. doi: 10.1097/ACM.0000000000003108
Other Suggested Resources
- MERIT Podcast by Drs. Chan and Varpio – Nature of Knowing
2. Meredith Vanstone – Philosophical Worldviews (macpfd.ca)
3. KeyLIME Podcast – Varpio consult #1 KeyLIME:  #1 The Best of KeyLIME from 2018. A Philosophy of Science Primer (libsyn.com)
4. KeyLIME Podcast – Varpio consult #2 https://keylimepodcast.libsyn.com/163-keylime-methods-consult-2-a-philosophy-of-science-primer
5. Goldenberg MJ. On evidence and evidence-based medicine: lessons from the philosophy of science. Social science & medicine. 2006 Jun 1;62(11):2621-32. Link: ScienceDirect
6. Varpio L, MacLeod A. Philosophy of science series: Harnessing the multidisciplinary edge effect by exploring paradigms, ontologies, epistemologies, axiologies, and methodologies. Academic Medicine. 2020 May 1;95(5):686-9. Link: Academic Medicine