that? The values that drive medical education scholarship and - - PowerPoint PPT Presentation

Why do you care about that? The values that drive medical education scholarship and research

AMEE Webinar, 10 May 2017 Ayelet Kuper MD DPhil & Cynthia Whitehead MD PhD The Wilson Centre, University of Toronto

Objectives

• By the end of this webinar participants will be able

to:

• Identify factors that contribute to their identity
• Link their identity to their values
• Distinguish between value-free and value-laden

understandings of the research process

• Consider how their values shape their medical education

scholarship/research

Outline

• 1. Introduction to Identity & Values
• 2. Ways in Which Values Affect Research
• 3. Values & Medical Education Research
• 4. Where to from Here?

Introduction to Identity & Values

Who Are We? What Do We Do?

• Ayelet Kuper
• Physician & Scientist in Medical Education
• My research program is driven by the need to question

taken-for-granted assumptions, like what counts as medical knowledge or what should be taught in medical curricula

• I also help to address the physician knowledge gaps

created by those limitations

• As I become more senior and can focus on what I value,

I’ve been doing more work related to the patient experience and to social justice

Why Do We Do What We Do?

• Ayelet Kuper
• I grew up in a family that was strongly social justice
• riented and politically engaged; I also have many

relatives who were refugees or who were affected by war or genocide

• Several years after I became a physician I spent several

months as the primary caregiver for a critically-ill hospitalized family member, which gave me a new understanding of the nature of the patient experience in the health care system in which I work

Who Are We? What Do We Do?

• Cynthia Whitehead
• Physician & Scientist in Medical Education
• In my program of research I interrogate assumptions

that underpin medical education practices, processes, and structures

• In so doing, I aim to expand our ideas about what is

possible and desirable in medical education

• My motivation to work in this way connects to the

values of equity and diversity

Why Do We Do What We Do?

• Cynthia Whitehead
• I am a ‘child of empire,’ born in a British colony and

tracing back four generations of relatives who worked as missionaries (educators and doctors) around the world. As an educator, doctor and researcher, I have an interest in decolonizing medicine/medical education locally and internationally.

Many Contributors to Identity

• Different frameworks exist for this
• For the purposes of this workshop, we will use a

four-part framework:

• Personal
• Professional
• Social/Cultural
• Contextual

Many Contributors to Identity

• Personal
• Your own personal story
• The stories of your family and local community
• Recent events
• History passed down from previous generations
• Professional
• Your education, training, and/or work experience
• As an academic, a clinician, an educator, etc.

Many Contributors to Identity

• Social/Cultural
• An identity you take on for yourself because of your

engagement with a cultural, religious, or other group

• Contextual
• An identity imposed upon you because of other people’s

assumptions about you and because of power dynamics active in your context

• In our context in Canada, relevant factors include things like

class, income, job, gender, race, religion, age, and (dis)ability

• In your context, these categories (or perhaps the hierarchy of

what’s better or worse within them) might be quite different

Writing Exercise Part 1

• The technology limits what we can do interactively
• Instead of a Think-Pair-Share exercises, we’ll do

Think-Write exercises (and we can try to share a bit as a group if some of you want to)

• In our experience, writing exercises with optional

sharing can actually be better for potentially sensitive, personal subjects

Writing Exercise Part 1

• Take a minute to list three things about yourself

(which could be personal, professional, social/cultural, or contextual) that contribute to the ways in which you see the world

• After the next question/slide we will try to share

some answers if the technology works and if anybody wants to share (entirely optional)

Writing Exercise Part 2

• For each one of those three (personal, professional,

social/cultural, or contextual) things, is there

• Something you focus on in your professional life

(academic, clinical, research, admin, other) because of it; AND/OR

• Something that you deliberately choose to avoid in your

professional life (academic, clinical, research, admin,

• ther) because of it; AND/OR
• Something that you would like to focus on in your

professional life (academic, clinical, research, admin,

• ther) because of it but don’t (and why don’t you?)
• Write for 2-3 minutes, then optional reporting back

Reporting Back

• If you want to share, type into the comment box

now and we will read it aloud to the group

• Whether or not you want to share, keep what

you’ve written for now – we will work with it again later on in the Webinar

Identities and Values

• This is supposed to be a seminar about values in

research

• So why are we talking about our identities and how

those identities link to what we do in our work?

• Our identities affect how we see the world (what

we do, what we think is important, and what we value) – so they affect the research questions we ask and the ways in which we choose to answer them

History: The Value-Free Ideal

• The separation of superstition and intuition from

testable, reproducible, and value-free findings was thought to be essential to the scientific revolution that began in the 16th Century

• Ever since (and to this day) many scientists have been

passionately committed to the idea of the objective search for truth in the natural world

• Within Faculties of Medicine, most approaches to

research still assume this “objectivist” stance

• Objectivism is: The notion that there is an absolute truth or

reality that can be discovered (outside of an individual’s feeling, imagination, and interpretation), so knowledge is neutral and objective

History: The Value-Free Ideal

• Since most medically-related research is conducted

within this objectivist paradigm, the history and values of the researcher are still seen as having little relevance in light of the ‘truths’ being tested

• r discovered
• In this paradigm, “ideal” science is seen as “value-

free” (and thus as free of anything, methodological

• r personal, that would bias its results)

The Value-Free Ideal in MER

• Until recently, medical education research (like most

medically-related research) was largely objectivist

• Many researchers still assert the possibility and

desirability of value-free objectivism in MER

• e.g., Best Evidence Medical Education (BEME)
• BEME aims to “make available the latest findings from

scientifically-grounded educational research” and create “a culture of best evidence education amongst individuals, institutions and national bodies,” to end what they describe as medical education’s legacy of reliance on anecdotal or

• bservational studies
• BEME’s ideal sources of data come from meta-analyses and

randomized controlled trials (RCTs), which proponents argue provide value-free results.

The Value-Laden Thesis

• Most contemporary philosophers of science have

formed a new understanding of science that claims that values are inherent in all parts of research

• From choosing projects worthy of funding…
• ... to making judgments about the implications of the findings
• They argue that since values affect all aspects of

research, they ought to be acknowledged and better understood:

• That good science is ‘reflexive’, or self-aware (i.e., conscious
• f the assumptions which underlie and shape its research)
• That not to acknowledge the values inherent in scientific

inquiry leaves part of the research process unmonitored

• This is called the “value-laden thesis”

Ways in which values affect research

A Brief (and Selective) Overview

Extrinsic vs Intrinsic Values

• Extrinsic and intrinsic values affect different stages
• f the research process
• Extrinsic values affect science before and after

carrying out a study, guiding

• The choice to pursue a particular project
• How the results of a study are implemented
• Intrinsic values affect the research itself, guiding
• The appraisal of research data
• Choices between competing theories

Social/Cultural Values

• The science studies literature has shown the scientific

establishment to be an interconnected, homogeneous community that is difficult to infiltrate and to change

• The cultural uniformity of those who conduct scientific

research means the projects pursued are those that appeal to that particular cultural group

• In North America and western Europe, scientists are

disproportionately white and male

• If a single demographic defines the norms and nature
• f research, it makes it difficult to notice when one falls

into ways of thinking that aren’t ‘objective’ but are taken for granted within that demographic

• That makes it easy to miss out on perspectives from which we

could interpret data or design experiments more accurately

Personal/Commercial Interests

• The very possibility of conducting ‘value-free’

research is questioned in the science studies literature

• Personal and commercial interests can shape the

questions chosen, the populations studied and the contexts considered

• Even the ‘gold standard’ RCT only partially

eliminates bias from the research process; personal and commercial interests can still shape

• The experiment’s design
• The interpretation of data
• The publication and/or use of the results

Academic Publications

• Standards for academic publication in most medically-

related fields implicitly promote the value-free ideal

• Efficiency and simplicity are prized in scientific writing
• e.g., the notion of publishing “just the facts”
• However, some philosophers of science argue that it is

impossible to factually describe evidence without introducing values:

• Facts are deduced from a value-laden whole, and the

researchers determines which facts are relevant to report

• Factual and evaluative statements cannot be simply

separated

• All descriptive words have ethical/value-laden implications

The Value-Laden Thesis has Implications for All Research

• For researchers whose work is grounded in beliefs

about knowledge (’epistemologies’) other than

• bjectivism, accounting for their values is already

an important marker of rigour

• ‘Reflexivity’ is part of doing ‘good’ constructivist or post-

structuralist research

• Reflexivity is a particular kind of self-awareness
• Being conscious of one’s own personal, professional,

social/cultural, and contextual locations and how those affect one’s own values and one’s research

The Value-Laden Thesis has Implications for All Research

• The value-laden thesis means that objectivist

researchers also need to be ‘reflexive’

• In other words, the value-laden thesis means that
• bjectivist researchers need to consider the

extrinsic values that affect their research choices

• e.g., what led to the choice of the specific research

project

• e.g., what influenced the publication and/or

implementation of research results?

Values & Medical Education Research

Values and the Structures that Support/Govern Research in MER

• Earlier we mentioned BEME as an example of the
• bjectivist, value-free ideal in MER
• As part of the BEME process, individuals evaluate studies and

judge whether they are objectively valid or invalid

• BEME’s Board determines its strategic direction and
• versees/coordinates its activities
• Of the 36 BEME Board Members on the website
• 31 are from Europe or North America (the other 5 are from

Iran, South Africa, and Argentina)

• 31 are white
• 18 are men

Values and the Structures that Support/Govern Research in MER

• Drawing on the values-laden thesis one might ask: if

each member of an organization/committee brings his/her own norms to group decision-making, what social/cultural values are likely to influence decision- making about research?

• This includes what to study, how to study it, and how to judge
• ther people’s research
• BEME has obviously made an effort at gender-balance – is

this perhaps because of a recognition of the need to incorporate diverse values?

• Without an explicit discussion about values, can an
• rganization be certain that it is not just representing

the values of certain groups (likely those with more power in its society/culture)

Values and the Structures that Support/Govern Research in MER

• One implication of accepting the value-laden thesis

is the need for broad diversity in all stages of research

• From funding bodies to editorial boards and everywhere

in between

• This brings multiple different sets of values to the table
• This has been show to produce more innovative

research

Values and Individual Research Studies/Programmes in MER

• All researchers make assumptions (implicit or

explicit) about three things related to their research

• (1) ‘Ontology’: What is real?
• (2) ‘Epistemology’: How can I know what is true?
• (3) ‘Axiology’: What is of value?
• AKA “The Real, the True, and the Good”
• These questions are accepted as crucial

underpinnings of thinking in other fields

• An analysis of MER journals indicates that MER has

recently started to engage with the first two (ontology and epistemology)

• MER has yet to engage with the third (axiology)

Values and Individual Research Studies/Programmes in MER

• For decades (since the field began in the 1950s

until 10 years ago) there was no discussion of

• ntology or epistemology either
• As we alluded to earlier, until recently almost all of MER

was implicitly objectivist

• Experimental designs aimed to quantify educational

techniques, seeking evidence to support particular educational practices

• The value-free ideal was assumed, though rarely

explored explicitly

Values and Individual Research Studies/Programmes in MER

• In the past 10 years the field has begun to shift and to

embrace more diverse epistemologies

• In the process, there have been discussions/debates about
• ntology and epistemology within MER
• However, rigorous constructivist or post-structuralist

studies that explore phenomena in depth or consider a context holistically are still the minority in MER

• There is some attention to values in the published reports of

those studies, but even when non-objectivist researchers do want to write about this (which isn’t always), MER journals rarely want a detailed reflexive exploration of this in publications (even if word limits permit)

Where to from Here?

Is Value-Free Really OUR Ideal?

• MER is inherently a value-laden activity
• e.g., it is often said that MER is intended to improve

medical education, leading to better health care practices and potentially human health – these are all value-laden statements

• Why are we not thinking about our values?
• Is this a holdover from the history of our field?
• In other words, are we behind most other research domains

because of a residual lack of knowledge in this area?

• Or do we intentionally (as a community) still believe in

the value-free ideal?

How Could We Engage with Our Values as a MER Community?

• If we want to engage with our values, we will have

to think about (as a medical education community)

• How do we decide what values are (most) relevant?
• Who gets to choose/rank values?
• How does this link to the values we incorporate into our

educational and/or clinical practices?

• How do we incorporate our values into our research

practices

• As individuals?
• Within research-related institutions?

How Do We Engage with Our Values as Individual Researchers?

• Like many social scientists in MER (especially those who

use critical theory in their work), we fully accept the value-laden thesis

• We share a commitment to being ‘reflexive’
• That means: self-aware; conscious of our own personal,

professional, social/cultural, and contextual locations and how those affect our values and our research

• That means that, in terms of our research, we share a

commitment to ‘praxis’

• That means: research practice that is informed both by theory

and by reflexivity

• To do this, we have had to intentionally work (through

writing, reflection, etc) to understand what we value and why

Writing Exercises Thus Far

• In Part 1 we asked you to list three things about

yourself (which could be personal, professional, social/cultural, or contextual) that contribute to the ways in which you see the world

• In Part 2 we asked you whether, for each one of those

three things, there is

• Something you focus on in your professional life (academic,

clinical, research, admin, other) because of it; AND/OR

• Something that you deliberately choose to avoid in your

professional life (academic, clinical, research, admin, other) because of it; AND/OR

• Something that you would like to focus on in your

professional life (academic, clinical, research, admin, other) because of it but don’t (and why don’t you?)

Writing Exercise Part 3

• Looking back at your answers for Parts 1 and 2,

spend the next few minutes answering one or two

• f the prompts on the next slide
• We will then try to share some answers if the

technology works and if anybody wants to share (entirely optional)

Pick 1-2 of These Prompts

• Are there other aspects of who you are that contribute

importantly to the ways in which you see the world?

• Are there things you notice now that you focus on in

your professional life (academic, clinical, research, admin, other) because of what you value?

• Are there things you focus on that aren’t as consistent

with your values, or are there ways in which your values could play a greater role in what you focus on?

• Are there values you hold that you want to incorporate

into your work but can’t figure out how?

• Are there values you hold that you feel that you can’t
• r shouldn’t incorporate into your work?

Reporting Back

• If you want to share, type into the comment box

now and we will read it aloud to the group

• Please also share any reflections you have on this

writing exercise or on what you are hearing from the group

• This is not a place to criticize other people’s answers,

but rather to build on them to understand one’s own values and struggles

Other comments? Questions?

Thank you! ayelet.kuper@utoronto.ca @ayeletkuper cynthia.whitehead@utoronto.ca @cynthiarw29