Qualitative research and The BMJ

It may have occurred to many participants in this debate that the attitudes of those who favour qualitative approaches over quantitative ones, and vice versa, bear an interesting resemblance to the characteristic tendencies of the right and left cerebral hemispheres, to perceive and then act, in very different ways to each other. If the ‘dominance’ of one hemisphere, rather than a nuanced, shared role in perception and decision making, is the exception rather than the rule, this suggestion may seem an irrelevance. On the other hand, it may go some way to explain how so little progress has been made in the debate, how little ‘meeting of minds’ there has been.

McGilchrist has pointed out that if the left hemisphere were to overwhelm the world view of the right hemisphere, “ there would be a loss of the broader picture, and the substitution of a more narrowly focused, restricted but detailed view of the world, making it perhaps more difficult to maintain a coherent overview..... the ‘bits’ of anything, the parts into which it could be disassembled, would come to seem more important, more likely to lead to knowledge and understanding, than the whole, which would come to seem no more than the sum of the parts... Knowledge that came through experience, and the practical acquisition of embodied skill, would become suspect, appearing either a threat or simply incomprehensible.“ (1)

McGilchrist’s ability to illustrate the very different views that the two hemispheres have, and the different preferences and actions that follow from those views, may help us to understand better the apparent inability of people of goodwill and integrity, to appreciate what it is about another’s opinion, that makes it worthy of their consideration.

Animated, if bemused at times, this present debate may be another challenge for the BMJ, to recognise how far it has moved to a position suggesting left hemisphere dominance, dismissive of those whose views do not complement its own narrow focus.

“ ..since the left hemisphere is the hemisphere of What, quantity would be the only criterion that it would understand. The right hemisphere’s appreciation of How (quality ) would be lost. “ (1)

It is interesting, if depressing, that in recent years the BMJ has refused to explain the unprofessional and vulgar abuse in its pages and on its website, directed at medical homeopaths. Many are BMA members, subject to abuse and accusations of bad practice which one might expect the GMC to open an eye to, if many abusers were not senior colleagues.
The accusations have been referenced and rebutted, (2,3 ), on many occasions, and the BMJ invited to explain its motivation. Silence.

Homeopathic assessment and treatment are complex processes, not at all what RCTs are designed to assess. There is a small mountain of qualitative evidence demonstrating the effectiveness, acceptability and safety of homeopathic remedies. (4)

Medical homeopaths are concerned, not so much at the abuse directed at them, in the BMJ, but at the inability of the BMJ to realise that there is a broader picture than the one it sees and acts upon. The BMJ’s inability to see that broader picture has contributed to a negative milieu for homeopathy, reducing the availability of NHS homeopathy, inevitably increasing the sum of human suffering.
Good luck to those who argue for a more qualitative approach.

1 The Master and his Emissary. Iain McGilchrist. Yale, 2009.
2 http://www.bmj.com/content/351/bmj.h5083/rr
3 http://www.bmj.com/content/351/bmj.h5624/rr-6
4 http://www.facultyofhomeopathy.org

We appreciate the vigour and thoughtfulness of those who have responded to Greenhalgh and colleagues’ open letter and to our editorial. (1,2) We see this exchange of views, and the fact that we are open about our priorities, as very positive things. We’ve listened to the arguments presented, and plan to do two things.

Over the next few months we will be consulting with qualitative researchers to learn more about how we can recognise the very best qualitative work, especially that which is likely to be relevant to our international readers and help doctors make better decisions. In addition, we will shortly issue a formal call for research methods and reporting articles about qualitative research. (3) We hope that proposals for these articles will come from some of the authors of the Greenhalgh et al letter.

Byatt, Smith and Fuller argue that, just as with qualitative studies, findings from randomised controlled trials often are not generalisable either, and that we are being inconsistent in assigning a lower priority to qualitative studies. We agree about the limited applicability of many trials. That’s exactly why The BMJ’s clearly stated policy for more than a decade has been that we are unlikely to publish certain trials, especially placebo controlled trials, and that we give higher priority to comparative effectiveness and pragmatic trials that are done in real clinical practice. Bolland asks why The BMJ continues to publish observational studies with limited generalisability, for example the recent paper on potato intake in pregnancy. We try to choose observational studies that we think have implications for a broad readership and that are methodologically sound. When considering nutritional epidemiology studies we bear in mind important caveats such as those raised by Ioannidis, and we publish only a small proportion of the nutritional studies we receive. (4)

It would be hard to claim that our, or indeed any journal’s, week by week decisions about what to publish are reproducible. But we do aim to publish work that will be both accessed by readers and cited by academics, and we routinely track usage and citations. We now have consistent data, going back a decade or more, showing that qualitative studies are on average less frequently accessed in the first three months after publication (median times accessed=4,975 (Lower Quartile 3,623, Upper Quartile 6,237)) than systematic reviews and/or meta-analysis articles (median=9,272 (Lower Quartile 5,953, Upper Quartile 14,634)). On average they also are much less frequently cited than review articles and some other designs. Because we have fewer than 200 slots for research papers in the journal each year, we have to do all we can to make those count, for patients, clinicians, and the journal. The paradox, as noted by Richard Smith, is that while journals pursue increased citations, researchers pursue publication in high impact factor journals. (5) This is borne out by a qualitative study recently published in BMJ Open. (6) Luckily, The BMJ is not the only journal in the world, and even within the BMJ’s stable of journals, there are several in which qualitative research represents a substantial proportion of published articles: BMJ Open and BMJ Supportive and Palliative Care, to name but two.

In summary, there is not and never has been a ban on qualitative research in The BMJ but nor do we plan to introduce a quota. We are open to and will seek out the very best and most useful qualitative studies and we will continue to publish methodological articles that support good qualitative research.

1. Greenhalgh T, Annandale E, Ashcroft R, et al. An open letter to The BMJ editors on qualitative research. BMJ 352 doi:10.1136/bmj.i957
2. Loder E, Groves T, Schroter S, et al. Qualitative Research and The BMJ. BMJ 352 doi:10.1136/bmj.i641
3. http://www.bmj.com/about-bmj/resources-authors/article-types/research-me...
4. Ioannidis JPA. Implausible results in human nutrition research. BMJ 2013;347:f6698.
5. http://blogs.bmj.com/bmj/2016/02/23/richard-smith-qualitative-research-a...
6. Tijdink JK, Schipper K, Bouter LM, et al. How do scientists perceive the current publication culture? A qualitative focus group interview study among Dutch biomedical researchers. BMJ Open 2016;6:e008681. doi:10.1136/bmjopen-2015- 008681

Interesting to see Prof. Greenhalgh include quantitative results in her further response on the need for Qualitative research in The BMJ. Presumably she felt that the qualitative quotes she included would not have been persuasive enough alone. C'ést la vie!

As to the criteria by which the BMJ's Editors might decide they are out of touch, I am at a loss to help Prof. Greenhalgh. In a Britain beset by obesity, anti-social behaviour, drug and alcohol abuse, youth unemployment, family breakdown, tension over migration and loss of moral purpose for much of society, at least the Editors still understand that Climate Change is the No.1 issue.

I was amazed and alarmed by the editorial response to Trish Greenhalgh et al's letter. Surely the BMJ has a role in promoting critical evaluation of research findings and knowledge ? Yet, this response seems to indicate a regression to reductionist approaches, along with a serious failure to engage with many complex questions about clinical interventions, health and health care.

Maybe the journal needs to consider whether it might be more useful to consign some of the favoured RCT approaches to specialist journals (due to the problems with generalizability to the actual experiences of many patients) and develop an emphasis on questioning and critiquing received 'wisdom'.