Family Practice Vol. 19, No. 5, 557-562
© Oxford University Press 2002
Doing qualitative research in general practice: methodological utility and engagement
Department of General Practice, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin, New Zealand; E-mail: cjaye{at}gp.otago.ac.nz
Jaye C. Doing qualitative research in general practice: methodological utility and engagement. Family Practice 2002; 19: 557–562.
Received 15 February 2002; Accepted 13 May 2002.
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Abstract |
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 Top Abstract IntroductionWhat is general practice...Conducting general practice...‘How to do’...The philosophical underpinnings...ConclusionReferences |
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Abstract. General practice uses an eclectic range of research methodology. This includes increasing reliance upon qualitative research methods. There seem to be two distinct treatments of qualitative research within primary care and, in particular, within general practice research. The first is characterized by a purely utilitarian and technical focus, using a qualitative method because it is the most appropriate means of realizing the aims of the research, while the second is characterized by in-depth engagement with the philosophical and paradigmatic aspects of qualitative methodology. In-depth engagement with methodology and theory, and theory building, is an important aspect of masterate and doctoral research within social sciences such as education and anthropology, and in the discipline of nursing, but has not been a feature of qualitative research in medicine. A practical difficulty encountered within postgraduate programmes such as the one in which the author teaches is that when innovative qualitative techniques are used by GPs in their postgraduate research dissertations and theses, it is often beyond GP examiners’ own knowledge and experience, yet it fails to measure up to standards established in social sciences, particularly in sociology and anthropology where in-depth reflexive engagement with the theory and philosophy of qualitative methodology is expected. This paper suggests that the value of in-depth engagement with methodology when conducting qualitative research results in creative and innovative ways of conducting research that are consonant with the nature of general practice itself, and strengthens research findings. Therefore, as teachers of research methods and supervisors of research theses, it is important to encourage students conducting qualitative research to engage fully with theoretical and methodological issues.
Keywords. General practice, methodology, qualitative research, reflexivity, teaching.
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Introduction |
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TopAbstractIntroductionWhat is general practice...Conducting general practice...‘How to do’...The philosophical underpinnings...ConclusionReferences |
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The use of qualitative methods is increasing in general practice research. Thomas et al.,1 for example, found in a review of publications on general practice research that around half of the studies surveyed had used qualitative methodologies. Interestingly, they also found that academic GPs and departments were more likely to use qualitative methodologies.
This trend is reflected in the research conducted by GPs participating in postgraduate programmes in the author’s department. The more traditional clinical topics researched using quantitative methods are still initiated, but there are increasing numbers of topics with a broader orientation around practice that are researched using a variety of qualitative methods. These topics include primary health care in rural settings, the reasons why patients change doctors, GPs’ experience of disciplinary complaints, GP supervision, the ‘sick role’ in pregnancy and the experiences of parents with chronically ill children.2–9
The theses listed above were researched using a variety of data collection and analytical methods that are part of the social science arsenal. An apt description of this genre is characterized by the term social general practice research. The idea of social general practice research reflects both the issues that interest GPs and the adaptation of social science methodologies to research these interests. These methodologies include various interview techniques, narrative and text analysis, qualitative and quantitative surveys, observation and ethnographic techniques, case studies and group discussion.
While these methods are adopted for their utility, there is a variable degree of engagement and reflection by thesis students in the philosophical issues inherent in qualitative methodology and in their application or utilization of it. Similarly, there is variability in the degree of engagement with theory building and the complexity of this process, as well as the results of this process. One reason for this, perhaps, is the implicit pragmatic and technical focus of medical training and practice. Another reason may lie in the teaching of research methods courses within general practice and emphasis on the utility of qualitative methods over methodological engagement.
While in-depth engagement with methodological and theoretical aspects of research are important tasks for masterate and doctorate research in social sciences and nursing, it does not appear to be such an integral task for equivalent research in general practice. This paper discusses the relationship between general practice and qualitative research, and argues that while a traditional pragmatic and applied approach to research has a primary focus on the utility of research methods, social general practice research would benefit greatly from in-depth engagement with methodology.
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What is general practice research? |
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General practice research has been described as being fundamentally different from other types of medical research because of the nature or landscape of primary care, particularly the diversity inherent in the general practice environment, and the questions that arise from this context.10,11
There are varying opinions on what actually constitutes general practice research. For example, Herbert12 advocates that primary care research be action oriented and community oriented. Tilyard and Dovey13 suggest that general practice research is anything that arises from a question generated in practice and as such is critically dependent on the context of general practice. Crabtree and Miller describe general practice research as multilayered and complex, with legitimate focus on global, community, family and individual levels, as well as organ, genome and cellular levels. They suggest that the significance of general practice research is that it connects macro-level aspects of health and healing with micro-level aspects of specific primary care activities.14 Similarly, Thomas et al.1 found in a review of publications in general practice that general practice research ranges from clinical research to social problems, and the administration and organization of primary care.
There are obvious similarities between general practice and the social and behavioural sciences. Helman15 asserts that primary care research is moving towards being an applied social science as well as an applied medical science. The common features of general practice and social science are implicit in Shapiro’s16 description of general practice as an ecological science rather than as a reductionist science. Similarly, Stott17 describes general practice research as socio-medical research.
Ultimately, Herbert suggests,12 general practice research is generated and conducted in general practice or primary care settings, carried out by GPs, nurse practitioners and other affiliated academics who work in primary care settings such as epidemiologists, statisticians and social scientists, and above all has relevance to those conducting the research. It might or might not be action oriented, and could be pure or applied, interest driven or clinically driven.
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Conducting general practice research |
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Much of general practice and primary care research is based on the assumptions and perspectives of specialized biomedicine. However, biomedical researchers historically have given little attention to the relief of suffering, or to patients’ experiences of illness, treatment, and recovery—issues that are characteristic of general practice.18 The development of research methodologies in general practice goes hand in hand with the development of the discipline itself.14,16 Specifically, research methods were developed in general practice that could capture the "richness of texture experienced in family practice".19 As a result, general practice research is highly eclectic and not limited by a defined set of tools and approaches.10
Shapiro, in particular, argues for authenticity in general practice research. By this, she indicates that general practice must remain true to its own philosophical foundations and develop its own arsenal of research methodologies that are relevant and specific to the discipline, rather than attempting to gain legitimacy in the eyes of other biomedical disciplines by using traditional but inappropriate methods, and uncritically adopting the theoretical assumptions that frame research in other areas of medicine.16
Considering the parallels that have been drawn between social and behavioural science and general practice, it is not surprising that general practice has adopted the research methods associated with these fields.15,17 Tilyard and Dovey go so far as to suggest that this merging of social science research methods with clinical research methods in general practice research has overcome the traditional quantitative/qualitative dichotomy.13
There are several reasons why general practice research adopted qualitative methodologies. For example, Britten and Fisher suggested that general practice is open to qualitative methods because, like family practice, it involves listening to people and becoming involved in their world; something that is already a motivating force in many GPs’ work.20 Similarly, Helman noted that qualitative methodologies provide the most useful means of understanding why people behave in certain ways and for exploring the relationship between beliefs and behaviour.15 Qualitative methods are also very useful for researching previously unexplored topics, and for generating research questions and hypotheses.21
While there is agreement that qualitative methods are useful in exploring issues that are unique to general practice settings, it is suggested that these need to be modified in order to be useful to general practice.22 As in every research endeavour in every discipline, it is important that qualitative research methods are chosen because they are the most appropriate means of meeting the aims of the research.
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‘How to do’ qualitative research in general practice |
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In addition to publications reporting qualitative research undertaken within general practice settings, the last decade has seen an increasing number of publications on how to do qualitative research in general practice. Many of these are concerned with issues of technical utility and rigour. How can a researcher ensure that their findings are reliable and valid?21,23–27
There is an important semantic distinction to be made concerning the use of the term methodology. Methodology in traditional quantitative biomedical research is used most often in a very narrow sense to describe research methods, and is no more than a descriptive term for data collection and analysis. Methodology, however, has a much broader meaning in many social science disciplines such as social anthropology, sociology and education. It refers to the philosophical and epistemological underpinnings of knowing about the world, and the problematics of conducting research. Methodology differs from methods because it concerns the logical and philosophical assumptions of particular research methods.28 The volume by Crabtree and Miller29 attempts to situate qualitative or social general practice research and methodology within its philosophical and paradigmatic context.
There appear to be two primary issues concerning qualitative research being conducted within general practice postgraduate programmes in New Zealand. The first concerns familiarity and training in qualitative research on two levels: both the technical utility of the methods, and the philosophical or methodological issues involved in conducting qualitative research. Current undergraduate and postgraduate medical training does not necessarily equip medical students with the skills necessary for conducting and writing up qualitative research. This means that postgraduate GPs’ first research projects are most often embarked upon without the benefit of undergraduate training in social science and the practical and theoretical grounding this confers.
Some have suggested that the nature of general practice gives GPs a ‘natural’ affinity and ability as qualitative researchers. For example, Whittaker30 suggests that the experience of being a GP parallels the experience of being an ethnographer conducting qualitative research because the GP is based in the community over a long period of time and learns to understand local knowledge and many of the individuals in it. The interview has been likened to an ethnographic interview, coming to understand patients’ perspectives and understandings. Helman15 also outlines a number of similarities between GPs and ethnographers, the use of the case history method, taking of personal and social medical histories, participant observation of the community in which the practice is situated, and treating the patient within the context of his or her own family. Britten et al. astutely suggest it is a mistake to consider GP consulting the equivalent of qualitative interviewing. They argue that the orientation of the clinician to the patient is fundamentally different from the orientation or relationship between interviewer and interviewee. While the doctor translates the patients’ experiences and words into concepts that are consonant with etic biomedical models, the interviewer attempts to understand the interviewee’s experiences from an emic perspective.21
Britten et al. suggest that an apprenticeship model is useful in learning to do qualitative research, working alongside an experienced researcher.21 This is similar to the models expounded by Lave and Wenger, and Brown et al., who argue that authentic learning occurs within communities of practice.31,32 Ideally, the supervisory relationship within an academic department provides this. However, this form of apprenticeship works well when students are situated within a department. One feature of many postgraduate programmes for GPs in New Zealand is that they are distance taught. This means that the community of practice is dispersed and the legitimate peripheral participation within these communities to which Lave and Wenger refer is peripheral in a very literal sense!
The specialized training or apprenticeship that is required in order to conduct rigorous and methodologically informed qualitative research has significant implications in terms of time and resources.26 Part-time distance study combines with a lack of expertise in qualitative methodologies among academic GP supervisors and examiners to result in a failure by many thesis students to engage with the theoretical foundations of qualitative paradigms and methodologies. While there might be varying degrees of reflexivity, the resultant time pressure often means that qualitative methods are used predominantly for their technical utility.
The second issue concerns the review of qualitative research, both by reviewers for medical journals and examiners of research theses. Britten et al.21 argued in 1995 that there was a need for reviewers in journals who are familiar with qualitative research. Around this time, several guidelines on evaluating qualitative research were published.21,24,27 While the amount of published qualitative research in general practice publications is increasing, and editors are ensuring that methodological rigour is demonstrated in these publications, the problem of adequate supervision and examination of qualitative social general practice dissertations and theses remains, certainly in New Zealand.
A recent publication has warned of uncritically adopting a ‘cookbook’ approach to qualitative research. Barbour33 argues that while checklists have their place in conferring respectability on qualitative research and in convincing sceptics of its thoroughness and rigour, there is evidence that they are sometimes being used prescriptively without real engagement in the underlying methodological issues. In conducting qualitative research, it is a mistake to assume that one size fits all. She suggests that technical fixes (those enjoying greatest popularity are grounded theory, purposive sampling, multiple coding, triangulation and respondent validation) achieve little unless grounded in broader understanding of the rationale and assumptions behind qualitative research.
The value of methodological engagement in qualitative research lies not only in improved research standards, because they are defensible, but also in the continuing development of qualitative methodologies that are specific to general practice, and therefore contribute to the maturation of the discipline itself. Such engagement also fosters an attitude of creative problem solving in research rather than prescriptiveness.
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The philosophical underpinnings of qualitative research |
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The philosophical underpinnings of qualitative research are discussed in varying detail by a number of general practice academics and researchers and can be summarized briefly as follows.
- The goals of qualitative research are the usual point of departure from traditional quantitative methods. While quantitative research explores the relationships between discreet measurable variables and outcomes, qualitative research is used to explore meanings and patterns, inconsistencies and conflicts in people’s thoughts and behaviours.21,27
- The researcher is positioned very centrally in qualitative research. This positioning requires a high degree of reflexivity on the part of the researcher. They need to be aware of the way that their own position and their a priori knowledge and assumptions impact upon all aspects of the research: development and design, data collection and interpretation. Bias, in qualitative research, has a slightly different meaning and is dealt with in a different way from quantitative research.27,34
- Qualitative research is explicitly interpretive. Researchers acknowledge that the analytical process involves interpreting the meanings, values, experiences, opinions and behaviours of other people. This process has been described as descriptive-inductive to distinguish it from the hypothetico-deductive means of drawing results in quantitative research.30,35 There are a variety of analytical frameworks within qualitative methodologies that range from being explicitly intuitive and non-fragmenting, such as immersion– crystallization,36 to those that fragment and code data within strict frameworks, such as some types of discourse analysis and grounded theory techniques.37,38 However, the interpretive and interactive nature of the relationship between the researcher and that being researched means that the analytical process necessarily involves a high degree of researcher subjectivity. The variability of this subjectivity is often managed in qualitative research through various techniques that confer validity and reliability, such as triangulation, respondent feedback and peer review.
- This interpretive and interactive quality of qualitative research is a reflection of ontological and epistemological assumptions that often differ from those of traditional quantitative research. Most quantitative, and some qualitative research is underpinned by positivist and post-positivist understandings about the nature of the world and its ‘facts’, that it exists a priori and is measurable. However, much qualitative research is informed by constructivist paradigms that view the world and its ‘facts’ as fundamentally interpreted and constructed by individuals within social groups.39,40 Murphy and Mattson argue that this perspective is entirely congruent with much of general practice.35
There is growing recognition within general practice that the utility of qualitative methods should be accompanied by some degree of reflection and engagement in methodological issues.17,29,41 Malterud, for example, is adamant that evidence of reflection upon the preconceptions and theoretical frames of reference that frame the research process must be accounted for in qualitative health research.34 The value of reflexivity and engagement is practical in that the standard of qualitative research conducted in general practice is improved. It moves from being prescriptive and following a ‘cookbook’ approach, to being defensible and justifiable in terms of meeting research aims.42 It also becomes an enterprise in creative problem solving that fosters methodological innovation. There is also the potential that, as in other health fields, notably nursing, this engagement will contribute to an academic debate that is continually extending the trans-disciplinary dialogue surrounding qualitative methodologies. Barbour suggests that this potential is somewhat limited by the lack of a clear vocabulary in general practice at present for talking about the processes involved in theorizing.41
There is obviously a need for engagement with qualitative methodology to be generated within the discipline of general practice itself. The difficulty lies not only in the unfamiliarity of many general practice researchers with the theory that underlies qualitative research, but also in the relative recent emergence of general practice as a discipline. Crabtree and Miller problematize the paradigmatic underpinnings that general practice and primary care have inherited uncritically from other biomedical specialties. They argue that medicine has been reluctant to engage with theory because they have ‘Truth’. They point out that qualitative research adds a critical component to the discipline of general practice in that it challenges clinicians and researchers alike to critique the foundations of the scientific endeavour and to be reflexive and creative in practice and research.14
It is apparent that much qualitative or social general practice research is certainly conducted within the philosophical and theoretical foundations and assumptions that underpin traditional biomedical quantitative research with its positivist orientation. The adoption of qualitative methods is no guarantee of researcher reflexivity or engagement with the methodological issues of qualitative research. Many questions answered using qualitative methods do not require paradigmatic and theoretical reflection. For example, Murphy and Mattson suggest that the choice of qualitative or quantitative methods is purely a technical matter, although they qualify this by noting that understanding the philosophical and epistemological aspects of methodology enables an informed decision to be made.
The demonstration of philosophical or methodological engagement is compounded by journal requirements that papers be structured in the SIMRAD model, and that word limits be strictly adhered to. There is often not the room to discuss methodological niceties in these publications. As a result, there often is an implicit assumption about methodology inherent within short publications. For example, the recent publication by Oppewel and Meyboom-de Jong is typical of this. These researchers interviewed family members about their experiences of autopsy. Although it might be assumed that this research was conducted within an interpretive framework, nothing about analytical frameworks is mentioned, nor is there any discussion about the philosophical framing of the research.43 In a thesis, however, there are often different expectations by supervisors and/or examiners. To start with, there is much more room to develop ideas and to explicate the theoretical framework. However, if qualitative methods have been adopted as a utility only, then any discussion of methods is often quite limited and conducted in the more traditional style of quantitative research as a descriptive account of the methods of data collection and analysis. If examiners are expecting engagement with the philosophical and theoretical foundations that underlie qualitative methodologies, this technical utility style will fail to meet their expectations.
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Conclusion |
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TopAbstractIntroductionWhat is general practice...Conducting general practice...‘How to do’...The philosophical underpinnings...ConclusionReferences |
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Is it legitimate to use qualitative methods in social general practice research without engaging in the methodological issues of research? The answer to this question might be yes, but the point of this paper has been to argue that some engagement is necessary in order to conduct quality social general practice and qualitative research. This moves it away from being prescriptive and means that well-informed research is done with careful consideration of design, collection and analysis aspects, as well as an attitude of creative and innovative problem solving. Perhaps the quality of this engagement will improve as general practice matures as a discipline.
What should this engagement look like? Other social sciences have a history of academic debate in methodology. The point of this paper is not to suggest that methodological discourses in general practice should imitate those in other disciplines. Far from it. The author anticipates that the developing methodological discourse within general practice will continue to grow, becoming more complex as it matures and also strengthening its own discipline-specific character.
How can we encourage postgraduate GPs to engage with methodological issues? The answer to this question lies in encouraging students to develop critical and reflective attitudes toward what they learn in general. We should provide opportunities for students to become familiar with a variety of qualitative research designs across disciplinary boundaries and challenge them to consider methodological issues in the broadest sense, as well as the technical utility of research methods. We should also model qualitative research within our academic communities of practice, and allow our postgraduate students the opportunity to learn by participating within these academic communities.
We need to emphasize the creative and innovative problem-solving aspects of conducting research and we need to stimulate our students to problematize methodological issues such as representation and cultural relativity, as well as validity, credibility, reliability and authenticity. Students learn best by being able to build upon what they already know and making connections and transforming what they learn.44 However, in the process of engaging with methodological issues and the epistemology and ontology underlying these, students need to be challenged to explore fully their own epistemological and ontological assumptions about the world. Once explicated, these can be problematized, providing a base for transformative learning. In this way, social general practice research of the future may be truly innovative and creative, generated from within the discipline itself to meet its own needs.
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References |
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