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Discussing 'qualitative research' with Dr. Carol-Anne Moulton

I recently learned a little bit about qualitative research and thought that it would be interesting to discuss the topic. As I am not an expert in the subject, I have asked Dr. Carol-Anne Moulton to provide some insight by asking her a few questions. Dr. Moulton is a surgeon at University Health Network, Toronto (UHN) and associate professor of Surgery at the University of Toronto. She is also currently appointed as scientist at the Wilson Centre [TGH, University of Toronto] where she is conducting research on surgical judgment and the social psychology of surgeons.

AAAS MemberCentral: What is qualitative research, and how does this differ from quantitative research?
Dr. Carol-Anne Moulton, M.D., Ph.D., University Health Network, Toronto (UHN): Qualitative research is a method of inquiry to study phenomena that occur in naturalistic settings. It generally answers the 'how' or 'why' questions that are difficult to answer using quantitative methods. It gathers data from the natural environment and is often used in the social sciences with increasing application to the healthcare field. The sampling is usually focused and deliberate to get a rich description of the phenomenon of interest with numbers that are much smaller than in quantitative studies. Qualitative research is often thought to be hypothesis generating rather than hypothesis testing, and therefore does not start with a prior hypotheses. The two methodologies — qualitative and quantitative — are used to answer different questions and are best seen as complementary rather than competing.  Too often criticism occurs from one side to the other because of a lack of knowledge of the other and lack of respect and appreciation for different ways of inquiry.

AAAS MC: What place does qualitative research have in medicine?
Dr. Moulton: Medicine is a complex field of study that gives rise to many questions including those involving social interactions, human behaviors and decision making. Therefore, qualitative research has a big role to play in exploring these issues that cannot be explored using quantitative methods. Examples of the different types of questions that might be asked using qualitative inquiry are 'why are patients not compliant with their diabetic medication?', 'why do parents choose to adopt children with special needs?', 'how are surgeons affected by the need to manage their image in the operating room?'. As you can see the examples given are important questions and cannot be explored in the same way or the same depth without qualitative measures.

AAAS MC: What had compelled you to pursue this kind of research?
Dr. Moulton: My main interest when I started out my research program several years ago was to understand surgical judgment. This is a complex field of study that needs to take into account how surgeons think in practice and why they make the decisions they do. As well as how they are influenced by people, culture, and emotion. This did not lend itself to quantitative method but was a perfect phenomenon to study in the real world through observations and interviews of surgeons in practice.

As I learned about qualitative research, I discovered a whole new way of thinking about the world and it has definitely changed my perspective for how we think about truth and how we legitimize certain methods of inquiry over others because of these basic beliefs. With a better understanding of qualitative research, several more questions have arisen, such as, 'how surgeons react to complications' or ' how does managing our image affect our decision making' or 'how does stress, emotion, and culture affect surgical performance?'.

AAAS MC: From your experience, how receptive has the medical community been to this kind of research?
Dr. Moulton: I have had little trouble with having my work respected and valued by the medical community. I am lucky that I study a phenomenon that many surgeons and health professionals are interested in hearing about. I try and provide them with a language and a framework they can use to better understand how they think and how the social environment might impact how they make decisions.

Having said that, it is difficult for most people in the medical community who are steeped in the positivist tradition to understand the role of interpretation and construction of knowledge in qualitative research. We are used to hearing about p-values [statistical measure of evaluating significance] and RCTs [Randomized control trials] and have our own hierarchy of how 'real truth' is sought and demonstrated. With a little education and a lot of patience, most people seem to be able to grasp the ideas of qualitative research. So far, I have been able to obtain grants to continue this line of research and have had several invitations from the surgical and medical communities to talk about my research. So I think the acceptance is there even though they might not understand all the nuances of qualitative research.

AAAS MC: Do you feel that qualitative research will take on a greater role going forward?
Dr. Moulton: I do believe this yes. I think partially this will happen as people learn the methodology. This will open up a whole new set of questions that likely have gone unexplored in their areas of interest. I think we have come a long way in answering many questions but have started to get frustrated in many areas that involve human behaviour and decision making. We have also opened up our field in a much bigger way to social scientists and this is a great thing. They have helped us see our world in a different way and have helped us question many aspects of healthcare that have been previously assumed.

We are asking ourselves some big and complex questions of competence and have put more emphasis on the qualities of healthcare workers that involve collaboration, communication, and leadership -- breaking down some of the silos we have previously found ourselves in. It is certainly a methodology that is needed to inform many of our questions for how we might make things better and why things are not working the way we think they should be. I will certainly look forward to seeing the field grow in the next decade or so. And thank you for this opportunity to share what I have learned. 

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Aria Nouri, MD