How and why social science theory can contribute to medical education research

Abstract

In his article ‘From sick role to practices of health and illness’,1 Arthur Frank argues that although social science research methods are integral to medical education research (MER), social science theory has been under-used. He echoes calls by others for the greater incorporation of theory into MER2-5 and for the recognition of MER as a social science.3 Frank1 moves this agenda forward by providing a summary of five key theoretical frameworks in social science and suggesting how they might illuminate various aspects of medical education. The theories he discusses each represent a different paradigm; that is, they are grounded in differing assumptions about the nature of reality and of society. For example, Talcott Parsons,6 a structural-functionalist, understood society as constituted by stable institutions and norms; Harold Garfinkel,7 an ethnomethodologist, emphasised the role of individual agency in the creation of shared meanings about a social situation, and Pierre Bourdieu8 sought to overcome this structure–agency divide by examining how practice is both shaped by and reproduces social structure. The choice of theory to be drawn upon in a given research project will depend on the phenomenon to be investigated, what is already known about it, and the researcher’s own worldview, and will influence the selection of methods that can be used to answer the research question. As Frank explains in his discussion of Parsons, theories are equally useful for thinking against,1 and should always be applied critically. The choice of theory to be drawn upon will depend on the phenomenon to be investigated and the researcher’s own worldview There is work within MER which already engages with the theories Frank1 mentions, such as studies using Bourdieusian,9, 10 Foucauldian11 or narrative approaches.12 Nevertheless, there is a tendency for studies to mention theory in passing, as Frank1 notes, or to fail to identify a conceptual framework at all.4, 5 Drawing on Bourdieu, Frank voices concern that what is now valued in academia (what counts as capital in the academic field) is shifting towards volume of outputs and grant applications, reducing the incentive or possibility to engage in the slow, careful process of developing more abstract theory.1 This poses a particular challenge in MER, which is already oriented towards applied research9 and brief publications,5 rather than theory development. Like Frank, I believe that such tendencies should be resisted, not simply to promote the creation of theory for its own sake, but because, as Frank1 points out, medical education research and policies that are divorced from social science theory are at risk of overlooking the origins of the problems they are meant to address. There is a tendency for studies to mention theory in passing or to fail to identify a conceptual framework at all Citing Weber, a founding figure of sociology, Frank1 argues that social scientific theory is what allows us to connect research to ‘the fate of our times’: it situates our understanding of specific, local issues within a broader social and historical context. The relationship between theory and research is bidirectional: we can use observations drawn from specific research projects to contribute towards a theory of how contemporary society works, and we can use such theory as a lens through which to interpret the local situation. For example, a study of British medical students’ understandings of ‘professionalism’ might consider how their views reflect or challenge shifts in the professional status of medicine in the UK and, even more broadly, what they indicate about how the roles of the professions in general are seen nowadays. This, in turn, might prompt the question of whether national context plays a role in shaping notions of professionalism, directing further research with American medical students, for instance. Research into medical students’ experiences of online learning might usefully take account of theories on the emerging relationship between new media and youth identities, and might also contribute to developing these theories. The relationship between theory and research is bidirectional: we can use observations to contribute towards theory, and we can use such theory as a lens Some medical education researchers may question whether they should spend time applying and devising theories about society when all they want to know is how to improve medical education. The point is that these are not separate enterprises. We need only look at the history of medical education in the last century to see how social change (in terms of public expectations of doctors, the organisation of health care, widening participation in higher education, and technological advances) has impacted the structure and content of medical curricula.13 Even on a day-to-day basis, learning does not take place in a social vacuum: students’ reactions to what they are taught, and their judgements of what is important in the vast amount of material with which they are presented, are shaped by the society of which they are part,14 by the fate of their times. An understanding of this social context is crucial in delivering effective medical education. We need only look at the history of medical education to see how social change has impacted the structure and content of medical curricula Medical educators have the tricky task of not only tailoring education to the learning styles of present students, but of pre-empting and instilling the skills that will be required of future doctors. Here again, social theory can be helpful, as it provides a basis for predicting the outcomes of various interventions based on past observation, allowing social trends to be anticipated to some extent. Furthermore, medical education itself plays a significant role in society, helping to actually shape the fate of our times: medical schools wield power within universities, contribute to health care and also influence the health care of the future. Social science theories provide frameworks for exploring the ramifications of medical education for other social institutions. Incorporating such concerns into MER could potentially produce more reflexive studies by encouraging researchers to consider the influences on and influences of their research.15 Akin to ‘reflective practice’, reflexivity in social science refers to the practice of analysing the effects of our own position, beliefs and interests on the research we undertake in order to produce more robust findings.15, 16 Medical education itself plays a significant role in society, helping to actually shape the fate of our times If medical education researchers are to take up the challenge of engaging more fully with social science theory, the question of how they will learn about it must be resolved. Although some medical education researchers have social science backgrounds, many come from basic science or clinical disciplines. As Monrouxe and Rees5 acknowledge, getting to grips with unfamiliar research paradigms can be hard work. They suggest greater collaboration between researchers with different disciplinary backgrounds as one solution.5 The incorporation of workshops and sessions on theoretical perspectives at MER conferences is also a positive development. Ultimately, however, the best way to really grasp what the various social science theories have to offer is to read about them. Frank’s article1 is a great place to start.