Latest / Behind The Knife: The Surgery Podcast / Unlocking the How and Why: Qualitative Research in Surgery
Transcript
- BTK Qual Research Audio === [00:00:00] Welcome back to Behind the Knife. I'm Stephen Thornton, one of the Behind the Knife Surgery Education Fellows. Today we're talking about an exciting topic. It's Underexplored in the world of surgery. Qualitative research in surgery, when we think of research, often we picture randomized controlled trials, meta-analyses, and big data sets. But have you ever considered what we might be missing when we limit our research programs to quantitative lines of study? Consider this, say you wanna understand the teamwork, culture, or identity of your department or your training program. Or what? If you want to understand the values, priorities, and lived experiences of your patients, these sorts of things can be hard to measure quantitatively. So how are you gonna go about studying them and communicating your findings with interested audiences? Some of the most meaningful insights about how we teach, learn, and practice surgery come from talking to people. [00:01:00] Their words, their stories, and their experiences, and that's where qualitative research comes in. Today I'm thrilled to be joined by two leaders in this space. Professor Nicole Perez from the University of Illinois, and Dr. Maya Hunt from Indiana University. Thank you both for joining us. Do you mind introducing yourselves to our listeners? Sure. My name is Nicole Perez and I'm an assistant professor in the Department of Medical Education at the University of Illinois college of Medicine. And I am a sociologist by training and have been in this space for about four years now. Hi, I'm Maya Hunt. I'm a general surgery resident and surgical education fellow at Indiana University, and I'm wrapping up my Master's in Health Professions education at University of Illinois, Chicago. A lot of our listeners may not have hands-on experience with qualitative research. Professor Perez, I understand you came to health professions education by way of sociology, a field where qualitative [00:02:00] methods are more often deployed and have a really rich history. In broad terms, can you tell our listeners what exactly is qualitative research and what drew you to the space? Yeah, thank you for that question. I think that generally qualitative research really allows you to ask why and how questions and fundamentally qualitative methods. Is rooted in constructivism, which is a fancy word or a paradigm that views reality as socially constructed and subjective, where knowledge is co-created through the interaction of the researcher and participants. So rather than seeking objective truth qualitative methods really aims to understand how individuals make meaning of their experiences from their own perspectives. And so, a lot of topics in sociology. Um, although, you know, there's a really rich quantitative tradition in that field too. There's a lot of questions in sociology that needed [00:03:00] qualitative kind of methodological approaches. And so that's why I leaned onto that tradition and brought it with me to HPE. And then as I started to get more comfortable in health professions education, I was able to offer the qualitative methods course in, our program, the, the Master's in Health Professions Education here at the University of Illinois College of Medicine. And, um, Maya was one of my first students. And so that's when I started to really understand the utility and importance of qualitative methods across various medical specialties including surgery. Maya, what about yourself as a surgical resident? You're coming from a field that doesn't have quite as rich of a tradition in qualitative research. How did you first get exposed, and what about it did you find so compelling? I actually first got exposed to qualitative research., In college. [00:04:00] I took a sociology class for my major, which was on evolutionary biology, the human species. And part of that course was reading ethnographies and, really fell in love with qualitative study at that point and seeing just how rich descriptions and how much kind of a deep understanding of something you can get just from looking at things through another person's perspective. So I didn't necessarily think it was gonna be something that applied to my future career. When I took the class, I was just fulfilling my major requirements and then I got interested in medical education in. Medical school. And when I was applying to residency, I was encouraged to read,, the book, forgive and Remember, , managing Medical Failures by Charles Bosque. And that is a medical ethnography, examining surgical culture around failure and different types of errors that residents make. The book was really [00:05:00] impactful for me to see a lot of different ways that surgical culture is similar and also ways that it's changed and it made me wanna look more deeply into what other types of ethnography was available or other types of qualitative research. At that point I was not really interested in doing quantitative research. And so when I. Began my surgical education fellowship. I was really curious about exploring surgical culture, especially through qualitative methods, and ended up doing a qualitative thesis for my master's with Nicole, actually as my thesis advisor. Well, I'm, I'm dying to hear more about your thesis work in the MHPE. Can you tell us a little bit about how you applied qualitative methodologies to that context? Sure. So, , the question really came about from like, why are residents unionizing? So I explored the motivations and drivers of general surgery residents towards unionization and.[00:06:00] I thought this was really rich for a qualitative study because there are some quantitative studies about unionization. But anytime you do a quantitative study or already, or like a survey or anything like that, you're already presupposing what people are gonna answer by giving them a limited set of responses. Right. And perhaps there are responses that somebody might offer or want to say or feel that aren't being captured in a study 'cause they're not offered. And so I felt that. We weren't really asking residents themselves why they were unionizing. There were a lot of suppositions. And so I wanted to ask the residents directly, so I did. What about you, Nicole? What sorts of projects are you working on in the qualitative space? Yeah. My first kind of body of work in,, health professions education was looking at the community cultural wealth model or framework that's been used extensively in higher education. [00:07:00] Um. So I brought that with me in that lens to medical education and really wanted to, , do a qualitative project using that framework. And so I, was very much interested in bringing that with me because it's very much assets focused, assets oriented. And from what I saw in my early transition to medical education was that. A lot of the ways in which we framed underrepresented folks in medicine or minoritized folks was through deficit ways. Deficit orientations about, well, their MCAT scores are low, or they didn't have shadowing experiences, or their parents aren't doctors. Right? And so I came from sociology and higher ed where. We tend to kind of like turn that on its head and say like, what are actually the assets that these learners are bringing that we're overlooking? And so, um, I decided to focus on a subset of Latinx medical students and [00:08:00] residents to unpack various assets. So, in that framework. Terry also talks about cultural capital, linguistic capital, family capital, navigational capital. And there's a few more, but essentially I have now come out with a few papers from that study. In social science, but also one forthcoming in academic medicine on linguistic capital. So that was very much my first qualitative endeavors in this new space. And so, had a lot of fun doing that. I want to highlight the difference between inductive reasoning or approaches and deductive reasoning and approaches. And so in qualitative methods, we're mostly taking this like inductive approach, which is, which all it means is that we're using the data and working our way up which is very different than, traditionally a quantitative approach that is more deductive reasoning in which we're testing hypothesis, we're going top [00:09:00] down, right, to test a hypothesis. Whereas qualitative methods we are generating hypothesis where we're trying to, you know, intervene, add, refine, existing theories, right? And so I think that. The difference between inductive and deductive reasoning and approaches is very important when we're broadly thinking of, , qualitative research approaches. Maya mentioned that you mentored her thesis work. Have you been working with surgeons much in the qualitative space? Yeah, so I don't know if I should say this here, but surgeons tend to be my favorite students. , I don't know if this is like you're not supposed to have a favorite child,, but some of my favorite students coincidentally happen to be surgeons. We tend to get a fair amount of surgeons in our, um, master's program here at the University of Illinois College of Medicine. And, I just love when they take qualitative methods because for so long. Just like other folks in medicine they're [00:10:00] trained in a very kind of biomedical model. Yes or no, black or white. And so when they come to my class, it's this like completely different way of thinking and knowing. And so,. My favorite thing is when these students come to my class with like an idea of a project they wanna do, and then after they take qualitative methods, they completely take a 180 and do a different project. And so one example I love to, to share is of, , Connie, I know Connie is involved with this. Um. Podcast too in the past. And Khan is, um, someone that took my class and then after my class, she changed her project to looking at pregnancy loss among surgical residents. And so, um, she's wrapping that up as we speak. And so, you know, this project was something that she couldn't measure necessarily quantitatively, and it was one that was very, riddled with emotions and a topic that was largely overlooked in surgery. And so, um, [00:11:00] although a very difficult kind of topic to, to explore very much needed in this space. Nicole, you mentioned the deficit based model of what students lack versus the assets somebody brings that we're overlooking and how you can kind of have that 180, you were describing it the same with like, you know, people wanting to do projects and doing 180 and I think that when you are. Looking at quantitative, I think I see it more as a black and a white and qualitative, I see it a lot more as shades of gray. And so you may have aspects of you know, some things in one. It might be lighter over here, darker over here, but there's, um. Teasing out those different shades is part of qualitative research and identifying that there's more than just that binary. And I think that's also really important 'cause we're all different people. We all have different experiences and perspectives, right? And one person is not going to be able [00:12:00] to capture all of that. So being able to get that diversity of perspective, to get that more rounded view, I think is also, really beautiful building on those reflections, it really stands out to me that qualitative research seems to shine a light on areas of study that could otherwise go unexplored. What are y'all's thoughts on what we're missing when we don't include qualitative approaches to our understanding of surgery, surgical education and, and surgical care? If we don't include qualitative methods, you're limiting yourself to what you can measure with numbers. And there's a lot more in our world and in surgery and in surgical care than what can be measured with numbers. And so anything that's relating to, you know, feelings or emotion one, but also like, you know, experiences [00:13:00] phenomena I think you lose a lot. I think there's, it's also important to talk about the different kinds of methods that there's lots of different kinds of qualitative research. And so you have focus groups and semi-structured interviews in which you really just having a conversation with one or multiple people. And the conversation is, you know, asking specific questions that have been predetermined based off of the big question that you wanna ask, but there's also ethnography in which a researcher is embedded within an environment and analyzing really a culture or a larger phenomenon. And by being embedded in it, the, the data is. Not just observations and conversations, but piece of data. It's a lot more bringing together a lot of different types of information to construct the either theory or understanding of what's going on to describe it. And there are other methods than just those [00:14:00] two. So it's not that there's like one way of doing qualitative research. Nicole, do you wanna jump in here. Yeah. I think by, um, not using qualitative methods in a space like surgery, we lose out on a lot about processes, about why and how things work, mechanisms, right? And so, um, when we think about different types of scholarship, their scholarship of discovery, , what is it? How does it work? Why does it work that way? Qualitative methods can do a lot to get at the why and the how, which is what I had previously talked about when broadly introducing qualitative methods. And I think that. Building upon Maya's kind of analogy of like qualitative methods being the gray area. Uh, I think that's very much resonates with me as well because we're looking at nuance. We're not, you know, looking at p values and generalizing to like a whole population. Instead, we're [00:15:00] using a case to talk about how certain processes work, what. Surgery culture looks like at one institution or several institutions. And so these things are a lot more difficult to kind of neatly capture. And it's messy, which makes people feel uncomfortable, that it's messy. But I think a lot of times again, we're dealing with humans and we are messy. But also if you're a surgeon, you exist in a field that shouldn't be messy, right? Like we want people to have, a diagnoses, we want them to be cured and we want them to, to, you know, go, go on and be healthy. And so that way of thinking is just so, not comfortable because for so long you've been socialized in your education and training to not embrace the messiness or the gray or the nuance. And so because we're conditioned, or you might be conditioned that way. [00:16:00] You might not find yourself asking those like more messy questions, right? 'Cause you might be overwhelmed with like, how do I measure that? Well, what if we don't have to measure something and instead we just like have a conversation with someone in a rigorous way, right? Because, um, qualitative methods are rigorous. And then we find out that we can extrapolate and come to thematic patterns to make sense of. Different processes in surgical education, for example. Well, and building off of that, you can then use those findings to develop a survey to see what is, to see how prevalent this is in different populations. Right? And so you can utilize this as the basis of a lot of quantitative research as well. I think that we are just a lot of times missing the qual background when we develop quant projects. But I agree with what you were saying also, Nicole, about context and we're talking about nuance, right? [00:17:00] Context is one of my favorite things. When you were talking about nuance and like this is all about context. So much of qualitative relies on not just what someone's saying, but what else is going on around that informs their perspective. And so it does make it more rich, but you're right, it does make it harder. But I think that even though it may, it does complicate it. I think that's what makes it so fascinating and interesting is getting to explore that messiness. Yeah, so much of our training in medicine writ large and surgery specifically, is about converging on a single answer to a problem, whether that be the right answer or the best answer, and it seems like that's not necessarily how you approach qualitative science, which seems to me more about divergent thinking and considering the truth that lies within multiple narratives. I really like the way that you described Maya, the relationship between [00:18:00] qualitative and quantitative work. Informing one another in this iterative process that increases the rigor of both types of, of inquiry. Uh, I, I'm wondering if either of you could talk more about times where you've seen that done well, qualitative work in forming quantitative work and vice versa. Not to be negative, but I can talk about it. In cases where it's not done well. Um, so something that bothers me is when studies talk about that they used mixed methods, right? They say we use mixed methods and we did a survey and we have open-ended questions in the survey. That's not mixed methods, that's multiple methods. And I wouldn't consider having open-ended survey questions on a survey. That being that warrants that you conducted qualitative methods. I think that that's, when we say we do qualitative methods, that means that we bring a [00:19:00] certain epistemology and way of thinking and knowing that has to undergird your whole study. It's not something that you can like, add ad hoc to a study. There's different assumptions that come with that. Um, and so I think that, a lot of times what's popular in med ed or HPE research is focus groups that I feel like that's done well is that this community's really good at doing focus group research, which is a, is a method, is a qualitative method that's then used to create survey instruments. And so I think that we have done that well in our field. And I'm wondering if. Maya's experience or you, Steven, if you know of any examples that have done the translational work or translational methodological work of using qualitative findings to inform like a survey? So yeah, so there's, there's one that is, I can think of off the top of my head 'cause I work with it really closely, which is second trial. So that's the surgical [00:20:00] education culture optimization through targeted intervention based on national comparative trial data. And basically it was, um, a large cohort of programs, we saw after the first trial, which was examining flexibility and duty hours and went on to help lead to the changes in the 2017, , duty hours for A-C-G-M-E. There was a finding in the group that while being was poor, there was high levels of burnout, and they wanted to understand why and what people were doing. Well or not well. And so, they did a huge number of tours of different institutions and did focus groups, semi-structured interviews, uh, with a whole bunch of people in the departments. And then utilizing those helped to craft and develop the surveys that they iteratively sent out without site. So that was one that was a big undertaking. Um, but they flew to different programs to talk to 'em in person, . , There's also an example. Um, there's a [00:21:00] paper by Ang et all from 2019 about why women lead surgery and it was conducted in Australia and New Zealand, but uh, it's a qualitative, exploration and they describe the reasons, not as usually one big reason. But as these kind of building blocks that this tower of blocks that stacks up and becomes more and more precarious. And then as this final block comes on, the whole thing falls, falls apart and women will leave. And so, I think, you know, we can measure what's the percentage of attrition in surgical faculty among women, but it doesn't really necessarily give us the why. And so having that background to understand, well, there's a host of factors do we want to include potentially to see what those are? How prevalent are these factors that are institution to send out in a survey? Things like that, that can be used, , are a good way of utilizing qualitative work to inform your future studies. I feel like there's this perception in, in surgery and it, it probably extends [00:22:00] beyond surgery to much of academia, but that qualitative research isn't as rigorous as quantitative work. I'm curious how both of you would respond to that. Yeah, I think that this perception was also something that like sociology struggled with and it's like coming of a discipline, right? There's some departments where this divide and contention is still very real. You know, I won't name any specific institution, but there are some that it's very obvious who the quant people are, and it's very obvious who the qualitative people are. And, you know, so that's, that's a fact. And so when we look at the, um, perception in medicine or medical education this field also was very much founded through research. Primarily using quantitative methods. And so, as a newer field, I think that we're still trying to adapt and catch up to other methods and other ways of knowing and doing. But there are some [00:23:00] sub specialties that are more comfortable or more accepting of these, uh, qualitative methods, I should say. And, . I think that this is apparent in like journals, right? If you look at various journals, you could see like the uptick in journals, , using qualitative methods. And so a good example is, , JAMA Open Network is now, historically, they have had like a quantitative expert be involved with the peer review process. And now as of this year they have qualitative experts, which like makes me so happy because, , that just goes to show that we're trending in this like direction where it's being more accepted and that we're it's being taken more seriously, right? Like we're having experts be involved in the review process. And so I think that it's interesting because. Folks who have this perception perhaps are ones that have never been involved in this research, right? And so there are assumptions that [00:24:00] are kind of biased, right? They're in their own world of. You know, measuring things quantitatively, which have their merits and you know, I've done that work before as well. And so I can speak to, to both approaches that they're both necessary and useful depending on the research question that you have. But I think that when we are trying to measure rigor, there are different criteria, right? And so, one of my favorite things to kind of talk through is bias, right? Bias has. It operates differently in qualitative methods in quantitative, you know, approaches. We wanna get rid of bias. We wanna control for relevant variables to get rid of bias. Qualitative methods, we actually wanna be very transparent that we are biased and that that bias actually is not a bad thing. That my bias as a woman of color that's not in medicine that does research in this space, brings a certain value that, for [00:25:00] example, Maya might not bring to a project or she might bring value to a project that's looking at surgical education, right? And so, um, when we think of rigor and bias. That's something that I really wanna emphasize to students is, , that it's not a bad thing. I think something else to note is that all studies are biased because all humans are, 'cause we are inherently human. And so it's whether or not the biases are transparent in being discussed. And so what I like about qualitative research is that there are these positionality statements that you should include where you. You know, divulge what your positions are. Who else on your team has those positions? Were there other people involved who had differing positions to make sure that you weren't focusing on just again, a bias perspective. How, how are you, you know, reflexivity as well as like, how are you able to critically examine the assumptions that you're making about the data and [00:26:00] then what. How else could it be interpreted outside of. You know, my limited viewpoint, how might Nicole see this differently than how I'm seeing it? And I think that's why you need multiple perspectives and multiple people involved who have differing opinions in qual research. But I think, I think like you were saying, it's a misperception that qualitative work is not as rigorous. You know, all data analysis requires an element of interpretation. So whether the biases involved or acknowledged or not, they're gonna be present. And in quantitative research, a lot of times those aren't. Those biases or those points of view from which they are approaching the data are not divulged. And I think it, it would be helpful to have that. Yeah, you used this phrase, positionality and Nicole, you highlighted how people's individual identities potentially labeled [00:27:00] bias can really. Be a strength in qualitative work and allow you access to information and understanding that you wouldn't have otherwise. I mean, it sounds to me like Maya, you mentioned this study you did with resident unionization. That has to be a great example of this, right? Like I imagine what residents were willing to share with you as a peer was unique and defined by that peer relationship if you were to have done that study. Seven years ago as a med student, or 10 years from now as a faculty member, the data you would have access to and the meaning you would make of it would be different. It wouldn't be more right or less Right, but it wouldn't be the same data. Yeah, I do think the fact that I am a resident right now and talking to other residents about their experience removes a power dynamic that inherently would come based on a medical education being within a hierarchical system. And [00:28:00] so if I was a faculty member talking to a resident, I could imagine they might be nervous to tell me their true feelings or, um, perhaps. You know, only talk about a portion of their experience and not something else. And especially since I come from a non-unionized program in a state that really can't, can't get unionized I, it wasn't like I was doing this because I wanted to be unionized or I wanted to judge. It was purely just to. Ask them, how do you feel about this? Why are you doing this? What did you hear from other people? What's happened throughout the process? What was it like? How has it changed? How have your views changed throughout this? And I think the biggest thing was that residents expressed that they felt like. They were finally being heard because somebody was asking them the question. And so I think that's why it's important to inspire surgeons to do qual research is because you have [00:29:00] access in a way that a lot of people don't. Not only to operating rooms and to patients and clinics, but to the world experiences that you have that you can bring to these questions is also very important. There's also, you know, an idea of time that I think is important and is perhaps one of the biggest barriers to surgeon with qual research is because it's not you can't just pull something from a database and. Code your statistics and then, you know, analyze them and write about it. There's a lot more, uh, sitting, I would say with the data, reading it repetitively over and over, stepping away from it to then formulate your thoughts. Most of my ideas about my thesis happened before I was falling asleep or while I was washing dishes. Right there. These other moments where I'm. Enmeshed in my data and letting it stew in my head and then coming to the, you know, having these moments kind of pop through. I think it can be really [00:30:00] intimidating to try and pick up a new skillset or research methodology, but surgeons do hard things all the time. What are y'all's pieces of advice or pearls of wisdom for how to get your foot in the door with qualitative research? I would say start with like looking locally at your own institution. There has to be at least one person. It might be, , hard to find, but I, I almost want to guarantee that you'll find at least one person at your institution that, , is doing qualitative research. It might not be in your department or your college. You might have to like search outside. And then once you find those people just pick their brains. Just ask them kind of like what they're working on, have a conversation with things that you're interested in. You know, this field is very team-based, right? This field of health, professions, education, medical education, very team-based. So, I think beautiful collaborations come when we're able to collaborate with people. You know, as, as, as a [00:31:00] sociologist myself, you know, , the more that I can collaborate with people like Maya all the better because like she said, I don't have access to an operating room and so it's all the more important to either gain the skills so that this work can keep going. So that Maya can do like a really cool ethnography, which, you know, she can talk more about, , in the near future or you know, come up with collaborative teams that can, really leverage your skillset, right? Like your positionality of either being a surgeon or you know, being the methods expert and sharing those skills with your team Yeah, Nicole. I absolutely agree. There's bound to be. At least one person at your institution, , who's doing qualitative research, I also encourage you to just start reading qualitative papers. It can be in a surgery journal, a sociology journal, um, anything. But I encourage you to start reading and seeing , what kinds of topics are you interested in? Is there something that keeps coming out and bothering you that you wanna explore more? I think one of [00:32:00] the. BOS forgive and remember it took me like six months to get through it 'cause it's pretty dense. But a different ethnography book that I really like that I recommend to everybody pretty much is doctor's orders the making of status hierarchies in an elite profession by Tanya Jenkins. She's at UNC and she was embedded at a community and an academic program and. Wanting to understand how do MDs primarily end up at academic centers and DOS and IMGs primarily end up at or more often end up at community centers. And how does that segregation happen? Through understanding the lived experiences of the residents at these different institutions. And so over like several years of, you know, being there and talking to people, she was able to kind of. Put together the Screen Theory. It's a great book. Highly recommend it. But that's one place to start. I'm also a really big fan of cold emails. So even if somebody isn't at [00:33:00] your institution and you find a paper that you really like, you're, this is the only thing you're fascinated in and qualitative. Whoever wrote the paper, send, send the corresponding author an email and say, Hey, I'm a surgeon, I'm a surgery resident, whatever you are. And I have no experience in qualitative methods or you know, I'm just starting to get into it. Or I have a little bit and I'm really pa excited and interested in the stu this study, the topic that you're, you know, exploring. I was wondering if I could. You know, chat with you, see what possibilities there are for collaboration and how I could gain some more skills while potentially also providing additional access or perspective to, to give. So, I, I am never afraid to send a cool email. I think everybody should, should do it more often. I'd love to hear a little bit about where you're both hoping to take your program of research in the years to come. Right now I'm starting to kind of think more about so now that I did the work of like [00:34:00] speaking to learners and trainees about their own assets in medicine, I now wanna look at the other side of the coin. In assessment. So people, faculty, folks that are in positions to evaluate these learners. How do they see these assets? Do they see 'em or do they not? And why not? Um, I'm still thinking through the intricacies of like how to develop that study, but that's generally the direction that I wanna head in because I think that this matters for admissions to medical school. I think it matters for the transition to residency and it has a lot of implications for equity. Among different types of, , folks in medicine. Yeah, so I just, uh, actually yesterday submitted my thesis. . Uh, so I need to get that published. But from there, I think one of one of my collaborations that, um. I was just reached out to, to collaborate on a project about rationalization in medicine and really, which is like [00:35:00] basically a step towards bureaucratization and perhaps how that's influencing culture within medicine. So I'm curious about that aspect, but. I think for the long-term future, I am really curious about doing an ethnography that involves intraoperative teaching, I think, or just nuances within the or. I have, I, it's not something I've really explored at all, but it is something that I am very curious about exploring in the future. I want to thank you both for sharing some of your time today to come on the show and talk about your experiences with qualitative research. This has been really so great and, I've learned so much just from listening to you both. For our listeners, we'll link the papers and resources for getting engaged with qualitative methods in the show notes. And thanks again for coming along.