The BMJ’s stance on qualitative research is epistemologically naïve
The BMJ’s response [1] to Greenhalgh and colleagues’ open letter [2] and the journal’s articulation of its stance on qualitative research [3] suggest a worryingly simplistic understanding of epistemology - what constitutes valid knowledge - across both qualitative and quantitative methods.
The BMJ’s assertion that qualitative research does not provide generalizable answers is simplistic on a number of counts. Firstly, while qualitative research does not provide statistically generalizable data (nor does it aim to), it does generate theoretically generalizable data [4]. Generalising to theory enables qualitative research to, for example, identify and provide an in-depth understanding of the reasons why patients do not adhere to a drug or the reasons an intervention, which was used with success in one context, has not been effective in another. Such data explain the mechanisms behind social phenomena and are surely, not just relevant to, but necessary for the BMJ’s remit - to help doctors make better decisions and to improve outcomes for patients [5].
The editors’ understanding of generalizability is naïve for a second reason. The findings of quantitative studies, including Randomised Control Trials (RCTs), often cannot be generalised outside of the context they were conducted in. As illustrated in depth elsewhere [6], this is because RCTs cannot account for the complexity of social factors in the trail’s context that may have contributed to the intervention’s success or failure. In other words, they can tell us that the intervention works in the particular context it was trialled in but not that it works per se. Hence the need for qualitative studies to inform us as to why an intervention worked (or did not) so that we can understand what might be needed to ensure it works elsewhere, if we know it works somewhere.
Given these generalizability limitations in quantitative designs, the BMJ’s claim that quantitative studies are “more definitive” [1] and “provide firm answers” [3] seems to indicate an unfounded level of certainty and epistemological bias in favour of quantitative data. Our social world is complex [7, 8] and therefore highly challenging to investigate. Both qualitative and quantitative methods provide us with knowledge that has limitations and often is not definitive. The validity and generalizability of research findings needs to be assessed based on studies’ individual merits, not a simplistic quantitative/qualitative dichotomy.
If the BMJ is to deliver on its remit – to help doctors make better decisions and to improve outcomes for patients – it cannot afford to limit our knowledge to that produced by particular methods. In doing so it does a disservice, not just to the major contribution qualitative researchers make to knowledge in this field [9-15], but also to doctors’ and patients’ needs. The BMJ should revise its epistemologically flawed stance on qualitative methods and embrace a thorough search for knowledge on its important remit.
Dr. Louise Caffrey PhD
King’s College London
Division of Health & Social Care
Faculty of Life Sciences & Medicine
References
1. Loder E, Groves T, Schroter S, Merino JG, Weber W. Qualitative research and The BMJ. BMJ. 2016;352. doi:10.1136/bmj.i641.
2. Greenhalgh T, Annandale E, Ashcroft R, Barlow J, Black N, Bleakley A et al. An open letter to The BMJ editors on qualitative research. BMJ. 2016;352. doi:10.1136/bmj.i563.
3. BMJ. Resource Authors: Research 2016. http://www.bmj.com/about-bmj/resources-authors/article-types/research.
4. Bryman A. Social Research Methods. New York: Oxford University Press; 2008.
5. BMJ. About The BMJ. no date. http://www.bmj.com/about-bmj. Accessed 15/02/16.
6. Cartwright N, Hardie J. Evidence-based policy: a practical guide to doing it better. Oxford: Oxford University Press; 2012.
7. Plsek PE, Greenhalgh T. The challenge of complexity in health care. BMJ. 2001;323(7313):625-8. doi:10.1136/bmj.323.7313.625.
8. US Institute for Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press 2001.
9. Gabbay J, May Al. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ. 2004;329(7473):1013. doi:10.1136/bmj.329.7473.1013.
10. Kai J. What worries parents when their preschool children are acutely ill, and why: a qualitative study. BMJ. 1996;313(7063):983-6. doi:10.1136/bmj.313.7063.983.
11. The A-M, Hak T, Koëter G, van der Wal G. Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ. 2000;321(7273):1376-81. doi:10.1136/bmj.321.7273.1376.
12. Curry LA, Nembhard IM, Bradley EH. Qualitative and Mixed Methods Provide Unique Contributions to Outcomes Research. Circulation. 2009;119(10):1442-52. doi:10.1161/circulationaha.107.742775.
13. Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. The Lancet. 2001;358(9279):397-400. doi:http://dx.doi.org/10.1016/S0140-6736(01)05548-9.
14. Sasson C, Forman J, Krass D, Macy M, Kellermann AL, McNally BF. A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols. Circulation: Cardiovascular Quality and Outcomes. 2009;2(4):361-8.
15. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ : British Medical Journal. 1995;311(6996):42-5.
Competing interests:
No competing interests
16 February 2016
Louise Caffrey
Research Fellow
King's College London
Division of Health & Social Care, Faculty of Life Sciences and Medicine, 5th Floor Addison House, Guy's Campus, London SE1 1UL
Rapid Response:
The BMJ’s stance on qualitative research is epistemologically naïve
The BMJ’s response [1] to Greenhalgh and colleagues’ open letter [2] and the journal’s articulation of its stance on qualitative research [3] suggest a worryingly simplistic understanding of epistemology - what constitutes valid knowledge - across both qualitative and quantitative methods.
The BMJ’s assertion that qualitative research does not provide generalizable answers is simplistic on a number of counts. Firstly, while qualitative research does not provide statistically generalizable data (nor does it aim to), it does generate theoretically generalizable data [4]. Generalising to theory enables qualitative research to, for example, identify and provide an in-depth understanding of the reasons why patients do not adhere to a drug or the reasons an intervention, which was used with success in one context, has not been effective in another. Such data explain the mechanisms behind social phenomena and are surely, not just relevant to, but necessary for the BMJ’s remit - to help doctors make better decisions and to improve outcomes for patients [5].
The editors’ understanding of generalizability is naïve for a second reason. The findings of quantitative studies, including Randomised Control Trials (RCTs), often cannot be generalised outside of the context they were conducted in. As illustrated in depth elsewhere [6], this is because RCTs cannot account for the complexity of social factors in the trail’s context that may have contributed to the intervention’s success or failure. In other words, they can tell us that the intervention works in the particular context it was trialled in but not that it works per se. Hence the need for qualitative studies to inform us as to why an intervention worked (or did not) so that we can understand what might be needed to ensure it works elsewhere, if we know it works somewhere.
Given these generalizability limitations in quantitative designs, the BMJ’s claim that quantitative studies are “more definitive” [1] and “provide firm answers” [3] seems to indicate an unfounded level of certainty and epistemological bias in favour of quantitative data. Our social world is complex [7, 8] and therefore highly challenging to investigate. Both qualitative and quantitative methods provide us with knowledge that has limitations and often is not definitive. The validity and generalizability of research findings needs to be assessed based on studies’ individual merits, not a simplistic quantitative/qualitative dichotomy.
If the BMJ is to deliver on its remit – to help doctors make better decisions and to improve outcomes for patients – it cannot afford to limit our knowledge to that produced by particular methods. In doing so it does a disservice, not just to the major contribution qualitative researchers make to knowledge in this field [9-15], but also to doctors’ and patients’ needs. The BMJ should revise its epistemologically flawed stance on qualitative methods and embrace a thorough search for knowledge on its important remit.
Dr. Louise Caffrey PhD
King’s College London
Division of Health & Social Care
Faculty of Life Sciences & Medicine
References
1. Loder E, Groves T, Schroter S, Merino JG, Weber W. Qualitative research and The BMJ. BMJ. 2016;352. doi:10.1136/bmj.i641.
2. Greenhalgh T, Annandale E, Ashcroft R, Barlow J, Black N, Bleakley A et al. An open letter to The BMJ editors on qualitative research. BMJ. 2016;352. doi:10.1136/bmj.i563.
3. BMJ. Resource Authors: Research 2016. http://www.bmj.com/about-bmj/resources-authors/article-types/research.
4. Bryman A. Social Research Methods. New York: Oxford University Press; 2008.
5. BMJ. About The BMJ. no date. http://www.bmj.com/about-bmj. Accessed 15/02/16.
6. Cartwright N, Hardie J. Evidence-based policy: a practical guide to doing it better. Oxford: Oxford University Press; 2012.
7. Plsek PE, Greenhalgh T. The challenge of complexity in health care. BMJ. 2001;323(7313):625-8. doi:10.1136/bmj.323.7313.625.
8. US Institute for Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press 2001.
9. Gabbay J, May Al. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ. 2004;329(7473):1013. doi:10.1136/bmj.329.7473.1013.
10. Kai J. What worries parents when their preschool children are acutely ill, and why: a qualitative study. BMJ. 1996;313(7063):983-6. doi:10.1136/bmj.313.7063.983.
11. The A-M, Hak T, Koëter G, van der Wal G. Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ. 2000;321(7273):1376-81. doi:10.1136/bmj.321.7273.1376.
12. Curry LA, Nembhard IM, Bradley EH. Qualitative and Mixed Methods Provide Unique Contributions to Outcomes Research. Circulation. 2009;119(10):1442-52. doi:10.1161/circulationaha.107.742775.
13. Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. The Lancet. 2001;358(9279):397-400. doi:http://dx.doi.org/10.1016/S0140-6736(01)05548-9.
14. Sasson C, Forman J, Krass D, Macy M, Kellermann AL, McNally BF. A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols. Circulation: Cardiovascular Quality and Outcomes. 2009;2(4):361-8.
15. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ : British Medical Journal. 1995;311(6996):42-5.
Competing interests: No competing interests