By Mairead Corrigan, Jenny Johnston and Helen Reid
We are a small research group working in medical education (#meded), a job which entails embracing and challenging subject, epistemological and methodological boundaries. One of us is a sociologist and two of us are academic GPs. We are fortunate to benefit from institutional support and wonderful colleagues. Even so, we still find ourselves frequently engaging in explanations of our research methods and epistemology to someone’s polite bafflement. Medical education is a broad church, drawing its membership from a diverse band of (among others) psychologists, sociologists, ethicists, clinicians/healthcare professionals and educational scientists. Each subgroup of medical educators brings their own understandings and cultural traditions to play. Even within the subset of clinical academics, there is a great variety of cultural norms and social practices, with identity based on specialty background. For two of us (H and J), our clinical background as GPs forms the bedrock of our educational work.
This polyglot mix makes the field of med ed research something of a patchwork, but also allows those within to draw great strength from its diversity. Coming together as a research group, we have realised that we work in a young and highly contested field. We are constantly learning to locate ourselves, and our relationships to each other, within competing epistemic traditions. We have begun to appreciate tensions and synergies, and to identify key assumptions in the literature which sometimes made no sense at all because they were written in an opposing tradition. Epistemological divisions are written large in our field, becoming a deeply personal matter of identity as people choose to embrace social scientific roles, or to align themselves with the world of clinical medicine. The dominant paradigm in biomedical research is strongly positivist. Medicine itself, in theory and practice, still builds on strongly dualist foundations. What Foucault termed ‘the clinical gaze’ is still highly influential; that is, a highly rational scientific and technological practice. Power is afforded to the clinician and the patient narrative is suppressed in favour of objectively elicited signs of illness.
For both of us who are clinicians, there is a deep tension between this worldview and our lived experiences of life and work as general practitioners. Such experiences inevitably raise questions about the constructed nature of illness, stigma and healthcare provision which inform our practice, teaching and research in medical education. A constructive dialogue is created between educational work and our similarly vocational clinical practice, deepening and enhancing both. For M, the sociologist amongst us, the strong emphasis on reliability and standardisation within medical education work against a lived understanding of illness experience. Here there is no right or wrong answer, only multiple shades of grey. In our experience, students sometimes may regard the sociology of health and illness and public health as of lower status than anatomy, physiology and clinical skills. As a sociologist, M works hard to keep the patient voice alive by exposing students to patient narratives.
It is clear that medicine’s positivist hegemony translates into medical education. Our constructionist research perspective jostles for position with an influential post-positivist psychology based on measurable traits and behaviours. This is not in any way to demean the large contribution of these scholars; rather, we want to highlight that benefits accruing from different epistemological perspectives have not always been well recognised. Journals often reflect these tensions. A reviewer from an alternate tradition can easily result in paradigm misunderstanding and friction. Existing as a boundary object between academic disciplines is a challenging situation for a researcher. There is a serious risk that neither tradition takes your work seriously. Interdisciplinarity is hard. Yet as educationalists, we believe our own careers are about lifelong learning, and we have a lot to learn from each other. As a team, we have all travelled on an epistemological journey. Ultimately, we have to produce work which can be translated into hard educational or patient outcomes, and as a group, we currently occupy a strongly constructionist and critical position.
Challenging a dualist, Foucauldian view of medicine is a prime concern for all three of us. Embodied illness experience and patient voice are powerful teachers, and critical perspectives have much to offer the developing doctor. Given that we train doctors, it is not surprising that discourses of accountability and technical practice are dominant. Sometimes our work counters these assumptions. More subtly, sometimes we choose instead to work with this dialectic to push two paradigms closer together, and so create new possibilities through symbiosis. We use the dialogue between our different experiences and perspectives to better use the cultural affordances of our field. Interdisciplinarity is a dynamic process of co-construction, of negotiation with diverse colleagues, of creating useful dialogues which benefit patients and doctors, of challenging cultural boundaries. Medical education is a grounded, pragmatic social science. We are critical researchers. We do things for the betterment of patient care and patient experience, and to improve the work and wellbeing of doctors.