Grounded Theory in Medical Education Research

Editor’s note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members. This issue of Academic Medicine is devoted to an exciting set of research reports, reviews, and commentaries selected for publication from more than 60 submissions as part of our ongoing collaboration with the Research In Medical Education (RIME) program.1–17 The topics are wide-ranging—experiences of moral distress among trainees, interprofessional team leadership, assessment and feedback during training, and the role of arts and humanities in professional identity formation, to name just a few. As in the past, each of these published articles will be presented and discussed as part of the RIME program at Learn Serve Lead 2024: The AAMC Annual Meeting, which takes place this month. RIME’s work highlights creativity and quality in education scholarship and communicates the importance of medical education inquiry to stakeholders throughout academic medicine, such as institutional leaders, promotions committee members, and learners. RIME articles elevate issues of concern to medical education in a timely manner. Such attention can lead to dialogue, consensus, and advances in the field. RIME also supports the professional development of medical education scholars. Manuscripts submitted for consideration by the RIME Program Planning Committee receive written feedback from reviewers and committee members, and service on the RIME committee itself is a valuable learning experience and opportunity for leadership in medical education and academic medicine. In celebrating RIME’s 60th anniversary in 2021, members of the RIME Program Planning Committee conducted a survey of past RIME chairs to better understand how RIME has helped advance medical education research.18 The past chairs recognized RIME as a catalyst for medical education research, strengthening the rigor and impact of medical education research, developing a community of scholars, and supporting academic career development. They also identified as priorities the need for greater innovation and translation of medical education research to practice. They welcomed new activities and collaborations, such as faculty mentorship initiatives and support for educators pursuing advanced degrees in education.18 Each year leaders on the RIME committee prepare a commentary, published as part of the RIME collection, that addresses a way to improve medical education research in academic medicine. In 2012, RIME leaders called for a more intentional, strategic, and inclusive effort. Medical education research requires an intellectual structure, a framework into which seemingly random studies can come together to improve learning and practice. The challenge before us is to look forward and develop a well-laid plan to further the field of medical education research nationally and internationally.19 For this year’s commentary, Sukhera and colleagues1 similarly challenge the field of academic medicine to do work that will improve learning and practice. They encourage medical education researchers to think beyond rigor, relevance, and utility in their work and to find ways to generate new knowledge that is readily—and will actually be—used. Drawing upon insights from implementation science, the authors call upon medical education researchers to mobilize toward actionable, scalable, impactful scholarship. Over the years, Academic Medicine has partnered with RIME to publish 30 journal supplements; RIME collections have also appeared in our regular issues in October 2012, October 2013, and November 2014. The editorial teams of Academic Medicine and our AAMC sister journal, MedEdPORTAL, have also been fortunate to benefit from the service of members of the RIME community, such as manuscript authors, creators of curricular and education resources, and expert reviewers. Authors of RIME articles have been featured on the Academic Medicine Podcast, which further increases the reach of the scholarly contributions. Academic Medicine also was pleased to collaborate with the leadership of RIME in 2022 when it launched its mentorship program for early and underrepresented faculty scholars, a program that has evolved to become MedEdSCHOLAR.20 This year, we are pleased to feature the RIME articles and commentaries in this issue of Academic Medicine. This decision reflects our continued strong support for the work of the RIME planning committee, RIME authors, and the broader RIME community in furthering medical education scholarship.

Likert-type scales are frequently used in medical education and medical education research. Common uses include end-of-rotation trainee feedback, faculty evaluations of trainees, and assessment of performance after an educational intervention. A sizable percentage of the educational research manuscripts submitted to the Journal of Graduate Medical Education employ a Likert scale for part or all of the outcome assessments. Thus, understanding the interpretation and analysis of data derived from Likert scales is imperative for those working in medical education and education research. The goal of this article is to provide readers who do not have extensive statistics background with the basics needed to understand these concepts. Developed in 1932 by Rensis Likert1 to measure attitudes, the typical Likert scale is a 5- or 7-point ordinal scale used by respondents to rate the degree to which they agree or disagree with a statement (table). In an ordinal scale, responses can be rated or ranked, but the distance between responses is not measurable. Thus, the differences between “always,” “often,” and “sometimes” on a frequency response Likert scale are not necessarily equal. In other words, one cannot assume that the difference between responses is equidistant even though the numbers assigned to those responses are. This is in contrast to interval data, in which the difference between responses can be calculated and the numbers do refer to a measureable “something.” An example of interval data would be numbers of procedures done per resident: a score of 3 means the resident has conducted 3 procedures. Interestingly, with computer technology, survey designers can create continuous measure scales that do provide interval responses as an alternative to a Likert scale. The various continuous measures for pain are well-known examples of this (figure 1). FIGURE 1 Continuous Measure Example TABLE Typical Likert Scales

Medical education research in general is a young scientific discipline which is still finding its own position in the scientific range. It is rooted in both the biomedical sciences and the social sciences, each with their own scientific language. A more unique feature of medical education (and assessment) research is that it has to be both locally and internationally relevant. This is not always easy and sometimes leads to purely ideographic descriptions of an assessment procedure with insufficient general lessons or generalised scientific knowledge being generated or vice versa. For medical educational research, a plethora of methodologies is available to cater to many different research questions. This article contains consensus positions and suggestions on various elements of medical education (assessment) research. Overarching is the position that without a good theoretical underpinning and good knowledge of the existing literature, good research and sound conclusions are impossible to produce, and that there is no inherently superior methodology, but that the best methodology is the one most suited to answer the research question unambiguously. Although the positions should not be perceived as dogmas, they should be taken as very serious recommendations. Topics covered are: types of research, theoretical frameworks, designs and methodologies, instrument properties or psychometrics, costs/acceptability, ethics, infrastructure and support.

Consensus methods such as the Delphi and nominal group techniques are increasingly utilized within medical education research. This educator's blueprint paper provides practical strategies regarding five key steps for ensuring best practices when using consensus methods. These strategies include deciding which consensus method is best, developing the initial questionnaire, identifying the participants, determining the number of rounds and consensus threshold, and describing and justifying any modifications. These strategies will help guide education researchers on their next study using consensus methods.

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

BackgroundMedical education research plays a critical role in improving patient care and advancing medical practices, yet the engagement among healthcare professionals remains limited. This study aims to explore the factors that influence participation in medical education research and provide recommendations to foster a research-inclusive culture within healthcare institutions.MethodsA comprehensive literature review was conducted across four databases: Web of Science, MEDLINE, Scopus, and Airiti Library. The search focused on studies published between 2002 and 2024, utilizing keywords related to ‘medical education research,’ facilitate,’ ‘engage,’ and ‘involve’. The initial search yielded 814 records. After removing duplicates and conducting a thorough screening process based on predefined inclusion and exclusion criteria, eight studies were selected for in-depth analysis. These studies were evaluated to identify key facilitators and barriers that influence research participation among healthcare professionals.ResultsThe analysis, guided by the Ecological Model, revealed a complex interplay of facilitators and barriers affecting research engagement. At the individual level, opportunities for professional development and career advancement emerged as significant facilitators. The interpersonal level highlighted the importance of leadership, mentorship, and peer support in fostering engagement. The environmental level, including institutional policies, funding availability, and protected research time, were identified as critical influences on participation.ConclusionsThe findings suggest that a holistic approach is needed to promote participation in medical education research, addressing factors at the individual, interpersonal and environmental levels. Recommendations include developing targeted strategies to improve intrinsic motivation among healthcare professionals, strengthening mentorship and peer support programs, and implementing supportive institutional policies that allocate dedicated research time and secure financial resources. By fostering a culture that values and facilitates medical education research, healthcare institutions can drive innovation in medical education, ultimately enhancing the quality of patient care and safety.

Medical education research faces increasing pressure to demonstrate impact and utility. These pressures arise amidst a climate of accountability and within a culture of outcome measurement. Conventional metrics for assessing research impact such as citation analysis have been adopted in medical education, despite researchers' assertion that these quantitative measures insufficiently reflect the value of their work. Every knowledge community has its own definitions of what counts as knowledge, how that knowledge should be produced, and how the quality of that knowledge production should be evaluated. Definitions of impact and knowledge shape and constrain researchers' foci and endeavors. Therefore, metrics that meaningfully evaluate the knowledge outputs of researchers need to be defined within each field. It is time for medical education research, as a field, to examine how to measure research impact and carefully consider the broader implications these measures may have. The authors discuss developments in research metrics more broadly, then critically examine impact metrics currently used in the medical education field and propose alternatives to more meaningfully track and represent impact in medical education research. Grey metrics and narrative impact stories to more fully capture the richness and nuanced nature of impact in medical education research are introduced. The authors advocate for a continual examination of how impact is defined, eschewing unquestioned use of conventional metrics. A new conversation is needed, as well as a research agenda to help medical education conceptualize and study metrics more appropriate for the field.

Feminism is for everybody

Background: The medical education research study quality instrument (MERSQI) was designed to appraise medical education research quality based on study design criteria. As with many such tools, application of the results may have unintended consequences. This study applied the MERSQI to published medical education research identified in a bibliometric analysis. Methods: A bibliometric analysis identified highly cited articles in medical education that two authors independently evaluated using the MERSQI. After screening duplicate or non-research articles, the authors reviewed 21 articles with the quality instrument. Initially, five articles were reviewed independently and results were compared to ensure agreed upon understanding of the instrument items. The remainder of the articles were independently reviewed. Overall scores for the articles were analyzed with a paired samples t-test and individual item ratings were analyzed for inter-rater reliability. Results: There was a significant difference in mean MERSQI score between reviewers. Inter-rater reliability for MERSQI items labeled response rate, validity and outcomes were considered unacceptable. Conclusions: Based on these results there is evidence that MERSQI items can be significantly influenced by interpretation, which lead to a difference in scoring. The MERSQI is a useful guide for identifying research methodologies. However, it should not be used to make judgments on the overall quality of medical education research methodology in its current format. The authors make specific recommendations for how the instrument could be revised for greater clarity and accuracy.

Over recent decades, the use of qualitative methodologies has increased in medical education research. These include ethnographic approaches, which have been used to explore complex cultural norms and phenomena by way of long-term engagement in the field of research. Often, however, medical education consists of short-term episodes that are not bound to single sites, but take place in a myriad of locations and contexts such as classrooms, examination stations, clinical settings and online. This calls for methodologies that allow us to grasp what is at stake in an increasingly multifaceted and diverse field. In this article, we direct attention to focused ethnography, which has emerged as a useful, suitable and feasible applied qualitative research approach, and which uses adapted classic ethnographic methods, such as direct observation, to gain new insights and nuanced understandings of distinct phenomena, themes and interactions in specific settings in medical education (eg the learning potential of ward rounds, or how hierarchical positions affect learning situations). We introduce methodological key features of focused ethnography to give insights into how the approach can be used, and we offer examples of how the method has been used in medical education research to show how it has contributed in different ways to the field of medical education research. Furthermore, we address and discuss some of the main challenges and limitations of the approach. Focused ethnography offers a methodological approach that sheds light over limited and well-defined social episodes and interactions. Precisely because the field of medical education consists to a large degree of such fragmented interactions, focused ethnography can be seen as a methodology tailored to these characteristics and should become an integrated part of the toolkit of medical education research.

Today we find a variety of national and international scientific resources that describe different versions of Grounded theory (GT). It is referred to GT authors (Glaser, Strauss & Corbin, Charmaz) and other researchers who apply different versions of GT and write about its fundamental strengths: systematic procedures, emancipatory decisions, self-empowerment of researcher to immerse into the data, and emerging theory being substantiated by empirical data and its interpretation. Reading the resources leads GT researchers to the understanding of this methodology as a set of systematic procedures which are applied in an integrated way by striving to the fundamental outcome – created original and based on empirical data GT. Researchers constantly applying GT alone may learn its principles, progress of adopting the necessary intellectual skills though at some point experience “being trapped”. Why? Because GT application does not stimulate their creativity and this methodology becomes “well-known” routine or “typical” process by recognizing what is “right” and “wrong”. Such attitude regarding the qualitative research methodology is risky due to emerging normative approach to the range of qualitative data collection, analysis and interpretation. Initially, the researchers’ self- empowerment to manage the different GT versions helps to avoid the routine. However, in this case there comes a time when each version is assigned by researcher with “labels”. For example, Glaserian version is named classic, emerging and theory-driven; version of Strauss and Corbin is seen as hypothesis testing, though in fact it is treated as a resource of hypotheses; in Glaserian version GT emerges, and in Strauss and Corbin version GT is forced. Constructivist GT version states that various social realities are relevant, and the common establishment of knowledge is recognized as outcome of cooperation between researcher and research participants. However, is it possible to find the emerging and forced moments in all GT versions? This question is not easy to answer accurately. There are similarities between the mentioned GT versions, though their differences are more conceptual than procedural. When researcher exploits his/her potential of creativity by applying a range of GT versions, then the time may come to make a decision to integrate GT and other methodologies. Thus, researcher’s attempts to combine GT with other methodologies being close to the emerging nature and plural data resources methodology of GT are creditable and deserve encouragement. The article presents the example of such decision when combination or integration of GT and Action Research (AR) is considered. Research question: Do similar features of GT and AR allow combining these methodologies aiming at validity of results within the research process? Research aim is to argue the possibilities to integrate GT and AR. Methods. The information in the article is presented consequently: each methodology is presented individually and then possibilities for integration or combination are discussed. The overview for analysis of possibilities to integrate GT and AR was used in the study by providing arguments and generalization of considerations. Conclusions. Integration of GT and AR illustrates the responsibility of researcher in shaping the design of a specific research and solving specific research issue. Decision to integrate GT and AR allows researcher to be the expert in both methodologies and strictly respect the principles, procedures, and methods. Researcher may not fully apply two methodologies, starting a study with one while concluding it with another. Such a decision is risky, causing uncertainty and leading to unreliable findings. However, the integration of these methodologies cannot and should not be a mechanical action. Researcher must clearly determine the object of the research – is it process or change? This will result in a clear and basic methodology of choice, respectively GT or AR. Then, the study will be based on the fundamental principles and steps of the chosen methodology. And the relevant components will be chosen by researcher in data collection and/or analysis of process (-es). GT and AR integration is possible, therefore GT and AR complement each other and their combinations depend of researcher.

Medical education research is underfunded. Little research focuses on basic issues of learning and teaching in medicine, and few educational innovations are tested across institutions to insure their generalizability. Despite repeated calls for the development of research organizations that would deal with substantial issues in medical education, funding remains a miniscule portion of the total budget for medical education. The author discusses how medical education research is supported in the present economic environment. The majority of published research is accomplished during the course of the researcher's employment. Many universities support pilot studies that lead to larger grants. Faculty development programs and career or academic awards support some research. Small to moderate amounts of funding are available through a variety of sources including medical specialty associations and private foundations. The author lists a variety of resources and strategies for finding foundations to fund research. Funding for larger research projects, particularly those that require more than a few years to accomplish or that involve multiple institutions, is more difficult to obtain. Federal training grants provide the laboratory for innovation and education research, but include inadequate funds to accomplish in-depth evaluation or research. The lack of emphasis on theory building and failure to prove the usefulness of innovations across schools cannot be overcome with current levels of funding. Medical educators must be advocates for the research support needed to move medical education research from a field with limited influence on practice to one that is able to connect sound insights and ideas with actual practices in education and improved patient health.

The field of graduate medical education (GME) research is attracting increased attention and broader participation. The authors review the special ethical and methodological considerations pertaining to medical education research. Because residents are at once a convenient and captive study population, a risk of coercion exists, making the provision of consent important. The role of the institutional review board (IRB) is often difficult to discern because GME activities can have multiple simultaneous purposes, educational activities may go forward with or without a research component, and the subjects of educational research studies are not patients. The authors provide a road map for researchers with regard to research oversight by the IRB and also address issues related to research quality. The matters of whether educational research studies should have educational value for the study subject and whether to use individual information obtained when residents participate as research subjects are explored.

Research into international information systems (IIS) is still a minority area in IS research and there is very little of use as a theoretical framework for researching them. Qualitative, theory building research is needed and grounded theory methods would be the most appropriate. However, grounded theory is a homocentric research method and IIS cases are a hybrid of human, social/organisational and technological case elements. To overcome this discrepancy, an amalgamation of Case study and Grounded Theory methods (CGT) is suggested and demonstrated on the case of a multinational IIS development project.

This review of Grounded Theory and Grounded Theorizing: Pragmatism in Research Practice, by Anthony Bryant (2017), aims to provide a perspective on the grounded theory method (GTM) from a pragmatic worldview. The book offers case examples of dissertations build on GTM. Bryant speaks about research in general, describes the development and an overview of GTM concepts, and provides step-by-step examples for practicing GTM. In this book review I, the reviewer, offer personal reflections as a novice researcher to GTM and pragmatism. I provide two “book-trailers” of the book that identify highlights of the book for me.