Pediatric Educational Learning Community (PELC) Session - “Introduction to Longitudinal Qualitative Research" - Dorene Balmer, Ph.D. - 4/24

May 22, 2023

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Pediatric Educational Learning Community (PELC): “Introduction to Longitudinal Qualitative Research" - Dorene Balmer, Ph.D. - 4/24/23

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00:00Because we've got a recording.
00:06As everybody knows,
00:07this is one of our monthly Pediatric
00:10Education Learning community series.
00:13But even though it's designed to
00:16support medical education so often
00:20the subject really in the topic,
00:23it just extends way beyond
00:26medical education in terms of.
00:29Methodology, the expertise of this speaker.
00:32And so it's actually my
00:35pleasure to introduce Good Jin,
00:38who is going to introduce
00:40our guests for today.
00:43Thank you so much, Panina.
00:44And it was so fun to to really read
00:48about Doctor Bomber's sort of path
00:50as she's been a mentor for me.
00:53So Doctor Doreen Bomber is a professor
00:55and distinguished chair in the
00:57Department of Pete's AT AT Upenn
00:59is and is a codirector of research
01:01on pediatric education at CHOP.
01:03Interestingly,
01:03her first career was in Clinical
01:06Nutrition at CHOP, but sort of really.
01:10Excited about the clinical
01:12learning environment,
01:12she ended up obtaining her pH.
01:14D at Temple University and Health
01:16Studies and Public Health,
01:17did a postdoc at Penn and launched her
01:20faculty career at Columbia University,
01:22which is during that time is when
01:24I was fortunate to have her become
01:26a qualitative mentor for me.
01:28She then spent some time in Texas
01:30at Baylor and returned to Upenn
01:31in 2015 and in her current role
01:34supports faculty and trainees in
01:36their sort of efforts and pursuits
01:38of educational scholarship.
01:40She provides direct consultation
01:42and mentorship for qualitative
01:43research methodology from project
01:45projects that range NIH funding,
01:47foundation funding and even just single
01:49sided department of funded studies.
01:51And and in her independent research
01:53is is super cool and focuses on
01:56identity and career construction
01:57and and has really pioneered A
01:59longitudinal qualitative approach
02:01to research and health professions
02:03education in which she's followed
02:06individuals including trainees
02:07and clinician educators for more
02:10than a decade decade.
02:11She's a past recipient of the APA
02:15Ray Helfer Award for Innovation
02:17and Pediatric Education,
02:18among so many other awards and honors.
02:21And impressively,
02:22she has published over 100 peer review
02:24papers related to health professions,
02:26education,
02:26and is currently writing a book that
02:28based on her longitudinal research,
02:30which I absolutely can't wait to read.
02:33Her work and mentorship have been
02:34really critical in my career path,
02:36and I'm so grateful to have her
02:38speak about a topic that she's
02:40taught me about and is and it
02:41really has so much expertise on,
02:43which is longitudinal qualitative research,
02:45and I'll turn it over to her now.
02:49Thank you, Gunjan. I really appreciate that.
02:53Before I I get started,
02:55I almost feel like just this is a warning.
02:57This is very slow research
03:01longitudinal think of it.
03:02I would say it's like a chronic disease.
03:04You sort of just got to keep it on
03:06hand it it's not a it's not an acute
03:10cross-sectional work it's it's longitudinal.
03:12So it's been just.
03:16A lot of fun and a lot about relationships.
03:21You when you follow people over
03:23very long periods of time,
03:25a lot of the lines between the researcher
03:27and the participants start to blur.
03:30And you really do understand,
03:34from my perspective as a
03:36qualitative researcher,
03:37as this idea of like code construction,
03:39it's really learning together.
03:42So I'm going to go ahead.
03:43I have a couple of slides.
03:47And we'll do a little bit of back and forth.
03:50There's a bit of a group activity
03:52since there's only and I don't
03:53think we'll break up into
03:57necessarily small groups,
03:58although I'll look to Gunjin if
04:01you think we should give me a nod
04:05and then I'll tell you a
04:07little bit about the research.
04:08But as we go through, please feel
04:11free to pop questions in the chat.
04:14Going in, if I could ask you to sort of
04:17just check that and and interrupt me,
04:20that's fine and we'll we'll go from there.
04:23So let me get my slides up here.
04:49So I'm hoping you're seeing
04:51my slides that correct. Yes,
04:53it's not in slide view yet.
04:54It's no, it's not.
04:55OK. Sorry about that.
04:56Just like Joe, let me
04:58get you over here.
05:25And you can go under
05:26Slideshow or press the little.
05:27I see, I see, I see.
05:37And either way, shares the screen first.
05:38Yeah, there you go.
05:39There you go. Got it. No.
05:40But it's still not in Slideshow mode.
05:42If you press that button at the bottom,
05:44that shows a computer,
05:45that'll get you there.
05:47Or if you go under slide
05:48show at the top and just
05:50say start from first slider.
05:51Yeah, but
05:51I've got two screens, Gungeon,
05:53and it's screwing me up.
05:54Oh, got you. I mean, you could
05:57do this too. We can see you
06:01like this.
06:04See, Heather, I should have
06:06practiced. We were right. I know
06:08we had that 15 minutes. No worries. I
06:12don't want that. close that.
06:18Just tries me to share.
06:29Sorry guys, don't worry,
06:34you might think I've never
06:35used. Feel free to send it to me too
06:36and I can share it if that's better.
06:45I think I never used Zoom before.
06:51Let me do this. It's not
07:02going to be perfect, but it's going
07:04to be good enough. How's that?
07:08I think that's that's totally fine.
07:09That's good enough.
07:10Good enough. Absolutely. Stay
07:11there. Wasted enough time. So
07:15yeah.
07:20This is me, the total Luddite when
07:22it comes to technology anyway.
07:24So what I what I really want to do is,
07:27is not to take more time with slides,
07:31I apologize, but to talk about some
07:33of the really important issues that
07:35come up when you do longitudinal work,
07:38things that really set it apart
07:42from other types of research,
07:44other and even other types
07:46of qualitative research.
07:47And then to share a little bit of
07:50some findings from a longitudinal
07:52study that that I've conducted in
07:55a group of physicians who went
07:58through the Masters in Medical
08:00Education program here at Penn.
08:02We'll talk a little bit about
08:05faculty agency And then to just
08:07highlight some practice pearls,
08:09some things like if you're
08:10going to try this on your own,
08:12what to sort of keep in mind
08:16before we even start let?
08:17Think about a definition of
08:19longitudinal work and it
08:23longitudinal work,
08:24qualitative research and sometimes you'll
08:26see it as qualitative longitudinal.
08:29It's called a few different things,
08:32but how I've defined it as it's an
08:36approach to research where you're
08:39generating data from the same
08:42participants over an extended period of time.
08:46So same participants,
08:47extended period of time.
08:49There's no, it doesn't have to be a certain,
08:51you know, six months, eight months,
08:53nine months sort of depends on the phenomena
08:55that the phenomena that you're studying
08:57in terms of the extension of that time.
09:00But you're doing that because you really
09:02want to understand lived experiences,
09:04which is probably a term you're familiar
09:06with if you do qualitative work,
09:08lived experience,
09:09but with longitudinal qualitative work,
09:12what you're doing is understanding
09:14those experiences.
09:15As they unfold,
09:17so you're not you.
09:20I mean, you can ask people to look
09:22back and there is some of that,
09:24but it's more walking alongside and
09:30that's particularly important if
09:32you're studying things like like
09:35processes like identity construction
09:38or how people create careers.
09:41I I think of you know some of Gunjan's
09:43work or some other colleagues of
09:45mine who are interested in say how
09:49the experience of of being in the
09:51the pick you and then the families
09:54that that that sort of journey to
09:57returning to somewhat state of normal.
09:59What's that like?
10:00It's not a one day you're in the pick
10:03you and the next day you're home and back.
10:06You know it's it's that journey in between.
10:10Again, we do longitudinal work to
10:12add to these sort of these insights,
10:14to some dynamic, idiosyncratic lived
10:17experiences as they play out through time.
10:21And it's it's doing this kind
10:23of work that really adds.
10:27Insight into things that we often think we
10:29know about and we we know something about.
10:32Safe from my work in career
10:34construction or identity construction.
10:36We know professional identity formation.
10:38We know different things about
10:40how people make career decisions.
10:43But when you follow people through time,
10:46you really sort of see this,
10:49a different side of it and and a
10:52nuanced side of it, and you see a past.
10:55And you see sort of pragmatic decisions
10:57being made in the present and you
11:00see them projecting into the future.
11:02So those are some of the reasons why
11:04we do longitudinal qualitative work.
11:08So let me ask you this,
11:09when you think about time as a scholar,
11:12as someone doing research via
11:14clinical research,
11:15education research or even just
11:17reading about research, how do you,
11:20how do you think about time?
11:25And I'm going to propose that there are
11:28two ways that we can think about time.
11:31There's more, but I'm going
11:32to suggest these two.
11:34One of a lot of times we think
11:36about overtime and we use that word
11:39overtime and a lot of the work we do.
11:42I'm saying in education like a pre post
11:45right a before and after or a follow
11:48up study where an intervention is done.
11:51And and then you're sort of six
11:53months out sort of seeing the
11:55impact of that intervention and
11:56that that before and after.
11:58But there's also this idea of through
12:01time it it's more of a crawl than a
12:06hop over time 1 to the other through
12:09time has this sense of crawling.
12:16That's not the only way to think about
12:18time because both of those times.
12:20If you think about it,
12:21we're a little bit more chronological,
12:23like attached to a clock or a calendar.
12:28So we think of time is fixed.
12:31We can think of it getting,
12:33in my world of of medical education,
12:35things like block rotations,
12:38academic years, semesters,
12:40things like that, there's fine.
12:42That's totally okay to think
12:45about time like that, but.
12:49A sociologist named
12:51Barbara Adams, in her book
12:55The Social Analysis of Time,
12:58really asks us to think about time as fluid.
13:04And by that she means that it's not
13:07just tied to a calendar or a clock.
13:09But time is fluid in that
13:11there's there's the best time,
13:13there's the worst, you know,
13:14great day, a lousy day, a best.
13:17Course, a good day, a lousy day,
13:19good time, bad time.
13:21Critical incidents is sort of a
13:24special unique time, mundane time.
13:26So there's there's time
13:27that has to do with like,
13:29just somewhat context dependent.
13:33There's also temporality.
13:34When you think of temporality,
13:36you think of seasons or rhythms,
13:41things moving and flowing through time.
13:46Ups and downs, seasons, rhythms,
13:48and there's also tempo or pace.
13:51Like a fast pace or a time is
13:54standing still or time flies by.
13:57So time is not just,
13:59I guess the the important piece there is.
14:00Time is not just this fixed
14:04calendar clock time.
14:05There's different ways to think about time,
14:09and when you do longitudinal work,
14:11you're really forced.
14:15To move beyond that calendar time,
14:19even though you are following
14:20people long periods of time,
14:21you can sort of see the past and
14:24the present being influencing
14:25and shaping the future and
14:27things become a little bit murky.
14:34So there's there's three couple
14:37of when I talked earlier in the.
14:40About the objectives that the critical
14:43really important things to understand
14:45and to know about longitudinal work,
14:47longitudinal qualitative work.
14:49And one of those is this idea of
14:53what I call a three strand analysis.
14:55It just means that when you're
14:58when you're doing longitudinal
14:59qualitative work it's you're not
15:01just studying a phenomena in a in
15:05a group of people or a context,
15:09you're actually.
15:10Following that phenomena through time,
15:13So it's that it's that delta piece,
15:16that change piece that makes
15:19longitudinal qualitative research just
15:22the spectacular approach that it is.
15:26So again, if you're studying
15:29something like food insecurity,
15:33you you could do that probably through
15:35a a survey or or maybe an interview,
15:38but if you want to follow.
15:40Food insecurity. Through time,
15:44you'd be tracking families and seeing how
15:48they move in and out of food insecurity.
15:52When you follow identity construction
15:55through time, it's not just this one set.
16:00Oh, now I am a pediatric resident
16:02and this is how I got here.
16:04It's like I'm, I was this medical
16:06student and I had to sort of.
16:08Change and see myself now as as
16:09an intern and I'm soon having to
16:11let that go because it's it's,
16:13you know spring and then I'm going
16:15to be a supervising resident.
16:16So it's it's this fluidity,
16:18this through time.
16:19So it's it's the case, it's the phenomena.
16:23But you had this third layer,
16:25this third strand of of time that
16:29makes analysis a little tricky trickier
16:31because you have this third dimension.
16:37The other thing that is I just can't
16:41imagine not doing with longitudinal work
16:43is what I call recursive interviews.
16:46And so that is taking data
16:48back to the participants.
16:50So you're sort of sharing their former
16:53cells and having them speak to their
16:56former cells as a way that they then
16:59sort of narrate their own growth.
17:02So it's as much of of becomes a.
17:05The interviews often become very reflective.
17:09Each interview is sort of constructed
17:11based on the their own participant.
17:13I mean there are main questions
17:14that we carry through,
17:15but if you're having to,
17:17you're sort of having to construct
17:19an interview guide for each person
17:21based on things they said in the past.
17:24So that recursive interviewing and that's
17:26just a way to sort of take the past,
17:28bring it into the present and and draw
17:31it into the future because you really
17:33again longitudinal you want that.
17:35Through time flow
17:39again, so just a bit of a recap
17:42definition generating data with
17:45the same participants through
17:48time to get that lived experiences
17:51as the experiences unfold.
17:53It's you know we we attend to
17:55both fixed and fluid time and we
17:57accommodate time in our data analysis
18:00and in our in our data collection.
18:04So maybe let me stop sharing now
18:07and ask before we go further,
18:09is there anything that I've said
18:11that is unclear or any questions
18:13come up so far you want to unmute
18:16yourself and just ask away?
18:18That would be just fine with me.
18:21Doreen, do you think you could
18:22just give maybe one or two
18:24examples of questions you'd want
18:25to ask on a longitudinal basis?
18:27I'm trying to like ground this in,
18:29in something concrete that
18:30I could think about.
18:31Great, great question. So something would be
18:38what is the journey of physicians
18:45doing a Master's in medical education
18:50program totally making that up
18:51or or what is what is it like
18:58for families experiencing?
19:00Food insecurity through time,
19:04so always bringing sort of that
19:06through time picture into the research
19:08question as opposed to what are they
19:11experiencing about food insecurity.
19:13Does that make sense, Melissa?
19:16And during one more question
19:17like in terms of when you're
19:18thinking about through time,
19:20is there sort of a minimum amount
19:22of time that you should follow
19:23somebody across for it to sort
19:25of count as longitudinal beta,
19:27the qualitative research, it's
19:29a great question.
19:31And the answer there's no time.
19:34I try to say it has to be at
19:37least nine months and I got
19:41a lot of disagreement.
19:42That's because a lot of the
19:44work that I do is education.
19:45And so you think of like a
19:48semester long type thing
19:52and there's there's some
19:54work again in education that
19:56suggests that maybe nine months.
19:58But it really depends on the phenomena and
20:02it could be as short as a a couple months.
20:05My colleague Lizzie Gordon from
20:07Dundee does some really interesting
20:09work and some of hers are,
20:11you know, 3-4, five, six months.
20:14Some of her work was around COVID.
20:16So understanding particularly that that
20:18first way, what was it like to be,
20:22in her case in Scotland at a a GP?
20:26And COVID in the first wave and so
20:28she would sort of follow that first
20:30couple of months and then, you know,
20:32it might have been a six month study.
20:34Yeah.
20:36Doctor Fenick has a question what
20:39everyone else knows about first names.
20:40And I'm Doctor Fenick.
20:41I'm feeling old. Hi, Doreen.
20:46I wondered, you know,
20:47has there been anything, you know,
20:48just like we have all of these
20:50different guidelines for how to write
20:52different types of papers. Is there a.
20:55A document that one can point to
20:57for methodology and rigor when we're
20:59trying to actually publish these,
21:01like we can do these.
21:03I actually did one without
21:05knowing what it was called, right?
21:08But where can we point to and say,
21:11you know, as in this guideline,
21:14here's what we did
21:18I. I don't know.
21:20So some of the work that I've done
21:22is is trying to publish methodology
21:25type methodology, type papers.
21:27So the one that I has probably gotten the
21:31most traction is time to conceptualize
21:33time and I can pop it in the chat,
21:35but it it's it's not a how to write
21:38up paper and some of that is because
21:45there's so many different ways to do.
21:49From my experience,
21:50there's a lot of different ways,
21:52just like there's a lot of different ways
21:55to analyze qualitative data most of the
21:57time and how we're taught in education,
22:00and I would say likely in clinical work,
22:01we're taught thematic analysis.
22:03Like you take a story apart,
22:06you take an interview apart and you
22:09break it down into like concepts.
22:12Code it.
22:12Put those codes together in new
22:14and interesting ways and voila.
22:15Theme. Right.
22:17So you're really deconstructing story.
22:20What I have found is that the more you do,
22:24and particularly the longer you go
22:28with an individual, you get story.
22:30Like the last thing I want to
22:32do is break the story apart.
22:34I spent 10 years putting the story together,
22:37so a lot of my work now is more narrative.
22:40Analysis where I'm analyzing the story
22:43as a whole and so then my my write ups
22:48are more stories than they are themes.
22:52I don't know whether that helps a lot Ada,
22:54but that's sort of where I've been
22:57going with it and it and it's just by
23:00virtue of the kinds of data that you
23:02get that you get story and so wanting
23:06to analyze data in a way that maintains.
23:09That the goodness of the story is there
23:16some guideline not guideline but like
23:18is there some thought you have as to
23:22how many people you need to follow?
23:24Longitude said In nine months is
23:26the time like a gestation right.
23:29OK fine but and and made that's
23:31kind of who knows but you know
23:345 residents over a year or.
23:37Two residents over here.
23:38I mean clearly 5 is better. It feels
23:41the the again the one no these are all,
23:44they're all good questions,
23:46all fair game, all like up for discussion.
23:50One of the things that you want to
23:53be aware of is the volume of data.
23:59It can get massive it can get
24:03massive pretty quickly so.
24:05In one study that I did it, I cut it.
24:08I ended it at 12 years because I started
24:10when they were first year Med students
24:12and I went through medical school,
24:14residency, fellowship and into practice.
24:18When I started that study at 22 I got.
24:21I stayed with the 22 through medical
24:23school and quickly realized there is
24:25no way in hell I can I can continue.
24:30Because I was interviewing every
24:32six months for a year.
24:33So you quickly have well over
24:36100 interviews and that just gets
24:38to be huge volumes of data.
24:40So a lot of it's the what's manageable,
24:42what's manageable And related
24:44to that is like who will stick
24:48with you and who really has it.
24:51I think you, I mean,
24:52I mentioned when I started about
24:53the idea of the relationship,
24:55you build a relationship with these
24:56people and you get pretty tight.
24:59And so you it's it's less of a I lose
25:01people and it's more like who is who's
25:03going to be with me in the from the
25:05beginning and want to and want to do that.
25:08And so there is some issues with Sam.
25:09It's a convenient sampling but
25:11if you don't have the sample,
25:13you can't do the study.
25:15So but again the length of it really
25:19depends on the phenomena you want to
25:22study and how long will it if you want to,
25:25if your question is about clerkship.
25:28Clearly you're going to go through the,
25:29you know or and you want
25:31to do longitudinal work,
25:31you sort of want to go through the year.
25:33If it's a transition out of
25:36residency into fellowship,
25:37then maybe it's a couple
25:38months before or whatever.
25:39So the phenomena will really define should
25:44help define the the length of of time.
25:51Cool.
25:54So what what we're going to
25:55do now is I'm going to go,
25:56I'm going to have a,
25:56I have a question here,
25:57maybe we can just talk through it again.
25:59I'll just ask you to
26:06think with me
26:09these four questions.
26:13We can see that Gungeon, right?
26:16Yes. They're a little paranoid.
26:20Consider the following four studies,
26:22and they all are interested
26:24in career decision making.
26:26And which one do you think is most
26:28likely to produce results that
26:30are consistent with the goals of
26:32longitudinal qualitative work?
26:34For LQR, you could conduct interviews
26:38with residents 3 months after they
26:41start residency and then again
26:44three months before they graduate.
26:45You could ask about.
26:47A career decision making.
26:49You could start with a cohort and then
26:52every six months sort of explore their
26:55their journey to becoming a physician.
26:58You could ask residents to write
27:00reflectively about their career
27:01choice at the end of the first year,
27:03second year, and 3rd year.
27:06Or you could interview,
27:08you know, P, GY1PG, Y, 2P,
27:10GY, threes and then sort of
27:13compare across those groups.
27:15They're sort of how they make decisions.
27:17So all of them are fine,
27:19fine ways to do research.
27:21But is there one that you think
27:24would be maybe the best way to
27:28capture the goals of longitudinal
27:30qualitative research or the
27:31goodness of longitudinal work?
27:42And I have some names of people,
27:44so I might call on people
27:47and it's like, yeah, it looks like and
27:50then they called put things in the chat. OK
27:52so people are in the chat. I'm gonna
27:54several people have said be in the chat be OK
28:00OK. So maybe Kristen or Nicole you
28:02said be could you tell us why be
28:08I think yeah I can give my
28:10impression I guess real quick.
28:12I think because I we were reviewing this
28:15concept that I really enjoy when you were
28:19describing it like through time and.
28:22Talking to those same cohort
28:24of residents through time,
28:26I think will help with this concept of
28:29the longitudinal qualitative research.
28:34And Nicole, or was that Nicole,
28:37that was Nicole, it's Kirsten.
28:39I think I like the idea of Nicole's
28:41statement about through time.
28:43I also think that.
28:44This would be a cohort that you
28:46would have access to on a red,
28:49you know, on through that time basis.
28:51So it would be feasible to to find
28:53this a cohort of residents maybe,
28:55perhaps I would start with
28:57interns and then go through
28:58their three years of residency.
29:00So even though it's a fixed time
29:02that you'll have access to them,
29:03it's still through time.
29:05Exactly, exactly. Yeah. Yeah.
29:07I think the first, I think the 1st.
29:11Questionnaire is that before and after,
29:13which again is is a fine way to do research,
29:15but you're you're going to probably
29:18get more two concrete points.
29:23C is you know, writing reflectively
29:25is great and you'd be asking that.
29:27You could even look at their
29:29reflections across or through time.
29:31What you won't be probably be able to
29:32do is like take back things that they
29:35said or that they wrote in the prior
29:37reflection and that idea of that recursive
29:39data collection is really important.
29:42And then interviewing P,
29:44GY1, twos and threes.
29:45Again, a really interesting,
29:47interesting study.
29:48But there you're going to be your N is
29:51really the group and not the individual.
29:54You're not really following
29:55an individual through time,
29:57but looking at looking at groups.
30:02Yeah. So let me move along here
30:07and and share with you a study
30:11that I think will be interested
30:13given the given the audience.
30:17So physicians as as you know get my next
30:26one advanced careers.
30:29In in academic medicine,
30:31by sort of following the some
30:35norms of things like we get,
30:37you know, we grant funding,
30:38you need publications,
30:39you need to be recognized as a
30:41leader or an expert in your field.
30:43It's pretty traditional.
30:47I'm at Penn, you're at Yale.
30:48We get that right.
30:52And that works for a lot of
30:54people in academic medicine.
30:56For physicians who are educators or really
30:58want to promote along the lines of education,
31:01not clinical work, a lot of times it's,
31:05you know, publications, Okay,
31:07maybe grants, probably not.
31:09But being I did, being a leader,
31:11like administering a program,
31:13being a program director,
31:14associate program director.
31:18Director of a Center for
31:19learning or something like that.
31:20Like that.
31:21So this idea of directing educational
31:24programs with administrative
31:26responsibilities is often you could
31:28use the word capital what what is
31:31valued and sought after for promotion.
31:33If you're a medical educator,
31:37however, directing programs is important,
31:41right? But it's not the only way
31:43to think about being an educator.
31:47So the question was like, well,
31:49what happens to my colleagues at CHOP,
31:52at Penn, at Yale, who really see
31:56themselves as educators but have like
31:58no interest in directing a program?
32:01Like the last thing they want to do
32:03is be a residency program director.
32:06Nothing against that,
32:06but that's just not how they see themselves.
32:09And and so then like what what how do they
32:12do, like what kind of agentic actions?
32:16Might their sort of their internal
32:18sense of being an educator provoke,
32:21if any, if any?
32:25If you look at the literature,
32:26a lot of this is where Ada,
32:28I'm going to talk about narrative.
32:30Now, if you think about the
32:31discourse or the larger narrative
32:33in medical education is like,
32:35oh, you know, we're not,
32:38we're dissatisfied.
32:39We're we're the ugly Dunklings,
32:41the second class citizens.
32:43This happens to us.
32:45So we, you know we have to sort of tolerate
32:48these these norms that are happening to us.
32:51But what the literature,
32:52there's a lot of that fact is just
32:55about all of it in in Med Ed is
32:57out there that is like you know
32:59fighting our way up in this field
33:01of academic medicine because these
33:03field norms are sort of in some ways
33:05out to get us or they're they're
33:07working against us and so there's
33:09very little out there about counter.
33:12Narratives or prototypes that
33:14people can use to understand.
33:17Stories about career advancement
33:19in different ways,
33:20in ways that push back on those field norms.
33:25And so my point in this paper is like,
33:27well,
33:28if we don't have these counter narratives,
33:30we're not going to,
33:31you know,
33:31it's going to be hard for us to sort
33:34of imagine what a different academic
33:36medicine future might look like.
33:39So we used a definition of agency
33:43from higher Ed called faculty agency.
33:47And faculty agency is a little
33:48different than a lot of other
33:51definitions of agency because it
33:52assumes both agency as something we do.
33:56The, the perspective, the actions,
33:59but it also considers agency
34:00as sort of a way of thinking,
34:03a perspective taking and intention.
34:05So it gets that intention,
34:07which sometimes precedes action.
34:08So you can also see where the
34:11longitudinality piece is sort of
34:12interesting here because you sort
34:14of want to know what happens,
34:16what's going on in their heads
34:17before they do an action,
34:19if they do an action at all.
34:22So the purpose was to describe and
34:24analyze how physician educators
34:26assumed strategic perception
34:27perspectives and took actions
34:29over the course of five years.
34:35So this was a longitudinal qualitative
34:37study that we started in 2016.
34:42All of the participants,
34:44there were 11 participants in the study and.
34:49They were all started the program
34:51in the fall of 2015 or 2016.
34:53We interviewed, we interviewed at the
34:55six month mark and then again at a
34:58year and then we followed them yearly.
35:00It's a two year program.
35:02We followed them three years out.
35:04So graduation post one year
35:06put 2-3 years post graduation
35:08for a total of of five years
35:12over the course.
35:14Against ADA, you talked about
35:15you did a longitudinal study,
35:17you didn't know it really I've,
35:19I've done that. This was a study
35:21that we didn't anticipate happening.
35:23What like they shouldn't say
35:25we anticipated the study.
35:26It was a finding that we didn't
35:28anticipate in that of the 11
35:31physicians in the in the study
35:34three of them over just in the
35:37course of following them took some
35:40really bold moves in their career.
35:46And we didn't, we couldn't predict.
35:47We didn't know that going in.
35:49We they volunteered to
35:50participate and we did.
35:52And then lo and behold,
35:52a couple of years down the Pike they
35:55made some pretty agentic moves.
35:58All three were assistant professors.
36:01All three, like the brothers in
36:03the study took we did the master's
36:06program and they these were the ones.
36:08That's three of the eleven who took
36:11these pretty substantial agentic.
36:13Perspectives and actions during
36:15the course of the study.
36:16So we did recursive interviews.
36:19Again, you can see the the
36:21number of interviews over time
36:25pretty much annually.
36:27We did this last interview on the 20 on in
36:31December of 2021 was a bit of an interview,
36:35but also taking back a narrative
36:39so that it looked like this.
36:40Our analysis looked like this.
36:43Using narrative analysis poking
36:45harms work was sort of like he
36:47this holistic and narrative.
36:49So like keeping it as a
36:51temporarily organized whole.
36:52So figure out how these pieces work together
36:55to to sort of tell you the whole story.
36:59So in phase one we did a sensitized review.
37:01So we had the data because this
37:03was part of another a study and we
37:05had looked at it from the lens of.
37:07Landscapes of practice.
37:08So we had the data,
37:09but this time we went back to the data with
37:11this idea of what is it going to look like.
37:13With faculty agency we constructed time
37:16order displays and this is something I
37:20always do with longitudinal work data,
37:22like how do you figure it out,
37:23even though this is, you know,
37:25in a bit of a fixed time,
37:26like just to know sort of where
37:28things are happening,
37:29what is this storyline looking like?
37:31So a time order displayed.
37:35Then we wrote from that display.
37:36We wrote counter narratives and took
37:41it back in that December interview,
37:43took it back to the participants and
37:46had them react, added some things,
37:49revised some things.
37:50And then we applied our theoretical lens
37:53and restory the counter narratives,
37:55really this time with the real
37:57sense of this faculty agency.
37:59And I admit, a colleague of mine,
38:02Amico Blaylock,
38:03is a higher Ed person who
38:05does narrative analysis.
38:07And so she really helped me with this.
38:09This is not something that came
38:11naturally to me or that I had a
38:13lot of experience with.
38:14But good partners are golden.
38:21So let me show you.
38:22This is one of the participants.
38:25This is Thomas.
38:26It's not his real name.
38:29Thomas was an anesthesiologist
38:33and he started his career in
38:37research and and pretty early he
38:41might even been at the instructor
38:42level realizing he just wasn't
38:44going to research was not for him.
38:46He was I'm tired of killing rats and
38:49so he got into he just was a great
38:51teacher and people loved it was
38:53students loved his teaching and he realized,
38:55Oh my gosh, like I really like education.
38:58And he and and he made the comment
39:00when we first talked, you know,
39:02where was his career going?
39:03He said, well, if it means,
39:05you know, I really love it here.
39:07But if it means going somewhere else,
39:09you know, I'm okay with that because my,
39:11you know, myself as an educator,
39:12I just love education so
39:14much and I'm here great.
39:15If not that's okay.
39:18He stayed at the institution and he sort
39:21of got pulled into some jobs an elective.
39:25Director and then sort of an associate
39:28fellowship program director and he he
39:31became more and more aware in the second
39:34year that you know what he valued as
39:36an educator and what the institution
39:38valued for promotion were just yes,
39:41he's they were just not In Sync.
39:45And so when we spoke the third year he
39:49said you're not going to believe this,
39:52I'm leaving the institution.
39:55He's leaving academic medicine, he said.
39:58And he said, now this feels active.
40:00Like before I was just sort of following
40:02these, these what I was doing,
40:03what wasn't valuable to me,
40:05it was valuable to the institution.
40:06But now by leaving the institution,
40:08this feels active.
40:09I'm doing what I'm not supposed
40:12to do by academic standards,
40:14and I'm leaving academic medicine.
40:17What he didn't remember is what he
40:19had told me in the very beginning
40:21about it's okay if I go.
40:24And sort of forgotten that piece of himself.
40:26So when he told me he's leaving,
40:28I said, well,
40:29you told me that two years ago
40:30he was just like, blown away.
40:31He said it just felt to me I was like,
40:34that's crazy.
40:35It feels like such an abrupt decision,
40:37but it actually had been on
40:39my mind for two years.
40:41So he did left the institution,
40:43left academic medicine,
40:45left on a high incident in all year #4.
40:48He's like down a little bit, right.
40:52I took this job.
40:53I thought it was going to be
40:54the director of education.
40:55I was working with a lot of
40:57advanced practice nurses and
40:58it just has not worked out.
41:00My understanding of education and
41:01their understanding of education
41:03just seemed really different.
41:04And he said,
41:05I'm really not sure what my life has
41:07to do with medical education anymore.
41:09So fairly dark Spot spoke to
41:13him by now the fifth year,
41:16and he talked about some dissatisfaction.
41:20Looking at other jobs,
41:22even getting back into academic medicine.
41:25And he realized, you know what? No.
41:29Before my agentic action was leaving.
41:32Now my agentic action is I am going to stay.
41:35I'm going to stay here.
41:37I'm going to make it work.
41:40So Thomas's story,
41:44the agency, the the, the,
41:46the, the bold move of actually
41:49leaving academic medicine.
41:51Making that move, thinking it's
41:52going to be on this high note,
41:54It wasn't really, you know what we expected,
41:56what actually happens or sometimes
41:58two different things.
41:59But then realizing okay.
42:00Now I if I made that decision
42:03before and use that word,
42:04you know, if I did that once,
42:06if I made that bold move once,
42:07I can do it again.
42:09And so he did it again,
42:10but he opted this time to stay in
42:13academic medicine and he did that or to
42:15stay to stay in actually private practice,
42:18I apologize.
42:19Left academic medicine,
42:20went into private practice and
42:22staying in private practice
42:23because his his intention is to
42:25make it work to be the educator.
42:27He wants to be in private practice
42:30but feeling like he has to had to
42:33leave academic medicine in order
42:35to have that values alignment.
42:41Samir's is one of the other ones.
42:44Samir started very he was
42:47fresh out of residency.
42:50Samir had a background.
42:51His, his parents were immigrants.
42:53And so he talked a lot about feeling,
42:56always feel like an outsider.
42:59And it was interesting because he felt
43:01like an outsider but really wanted to
43:03know like how to do it, how to get,
43:05how to make it work in academic medicine and,
43:08you know, trying to figure who's who,
43:10how do I play the game?
43:12And he said it's so easy to
43:14get caught up in that game,
43:15but then realizing that.
43:16By the 2nd year like or or or finishing
43:19towards the end of the program,
43:21towards the third year,
43:23realizing that what refreshes me and
43:25what recharges me and what rejuvenates me
43:28is not what I have to do to play the game.
43:31And he was very aware of having
43:35to be funded for his time.
43:37So if he would take an
43:39educational administrative role,
43:41he would be funded for his time.
43:43But again, that wasn't what.
43:46Refreshed, recharged and rejuvenated him.
43:49So what he ended up doing was
43:51going part time and he saw some
43:54of his peers cut back to 60% time.
43:58Reduces clinical so that anytime he
44:00was doing clinical work it was with a
44:03learner his his non learner clinical
44:06time he just cut took an you know a
44:10sizable pay cut to do that but that
44:12enabled him then to really pour himself.
44:15In some of his educational projects.
44:17And that's what refreshed him,
44:18recharged him and rejuvenated
44:20him and he realized, you know,
44:22at the end of the study year five,
44:24he said, I I,
44:25I know I made a choice to go part time.
44:28That's not a choice that
44:29a lot of people can make.
44:31But if I didn't do it for me,
44:33I would be miserable.
44:40So those are two stories from this study.
44:44Again started with 11.
44:46Three made these moves.
44:47There's three in the paper.
44:48For the purpose of this talk I just
44:51present to but one of the things that
44:53I think this what we can find and
44:56and and the one of the goodnesses
44:58of of longitudinal qualitative
45:00work here is it helps us to really
45:02understand and see agency is both
45:04a perspective and action that when
45:05the two pieces work together and one
45:09typically precedes another you can
45:11sort of follow that through time.
45:14The idea of counter narratives as
45:17sort of worthwhile knowledge that
45:19we can share and show others that
45:22there are alternative career paths.
45:24They have costs, not always perfect,
45:28but there are alternative career
45:30paths and this idea of of relation
45:33and and reflexivity.
45:37There's, there's,
45:38there's something that comes with
45:40building a relationship with people,
45:41with these, particularly these folks
45:43and what you can take and what they
45:46learn about themselves when they
45:48hear their former cells in the space,
45:50the real safe space that that can create it.
45:54It moves the relationship to
45:57this interesting spot of yes,
46:01you're the researcher, no,
46:02you're not the therapist, no,
46:04you're not the counselor, but the.
46:07By virtue of these kinds of recursive
46:10interviews and caring enough about
46:12people to listen and to remember
46:14what they said is is pretty powerful.
46:17And I think it's particularly powerful
46:19for physicians and particularly residents,
46:21fellows that really it's been my
46:24experience really sort of long for a
46:28space where they can just reflect on
46:32their journeys with someone that feels safe.
46:37And that they know cares about
46:39them enough to to listen.
46:41So that's sort of the the,
46:44the stories that I have from
46:48this, this longitudinal study.
46:51Any any questions I can take a couple
46:54of questions and then sort of wrap up.
46:57So Doreen quick question is what are your
47:01conclusions from that my mind immediately
47:04goes to reducing to themes versus.
47:07You know, what are your conclusions?
47:08Yeah. So the conclusions are
47:11just really that the the,
47:14the importance of of understanding
47:16agency is not just actions,
47:18but as perspectives and actions
47:20and the two work together and
47:23then providing counter narratives,
47:25putting something out there in
47:28the literature that showcases
47:30physician educators who push back on.
47:33The field norms of academic
47:35medicine in order to be true
47:37to themselves as as educators.
47:40So it's not the kind of thing that's
47:44going to lead to therefore do these
47:50things but but counter narratives can
47:53be really powerful teaching tools.
47:59Thank you.
48:02So let me. Go back now and just some
48:09Doreen, I actually have another
48:11question please. As you're gathering
48:13your thoughts, so you know that
48:17while you're creating these studies,
48:20how do you make them as
48:23generalizable as possible, right?
48:26I mean the the experience of multiple.
48:32Three members or or whatever.
48:33Like just thinking about the
48:34last study you presented,
48:35the experience of three people who
48:38all went through the hub system,
48:41hub chop, and got a master's
48:45in particular year, right?
48:48Does it speak to the experience
48:50of somebody at the University of
48:53Utah who maybe not may not be in
48:57a master's program and but yet
48:59is still in medical education?
49:01No, it doesn't.
49:02And we don't try to make it.
49:04It's this will not generalize it.
49:06No qualitative, qualitative research doesn't.
49:09It's not built on philosophical foundations
49:12that will work with generalizability.
49:15What we would try to do again in a short
49:18period when you read the narratives,
49:20it's much more of a story, and the more
49:23particular you can get with this story,
49:25the more people hold on to it.
49:27And I get it. So it's that idea
49:31of any kind of storytelling.
49:33We live by story. And so the the again,
49:37it's it's not trying to be generalizable.
49:40It won't be. It can't be.
49:41But if we can be generalizable or or
49:45or transferable in our in our detail,
49:49in our storytelling,
49:51hopefully they're compelling stories.
49:54They can say something about what
49:56it's like to be in academic medicine
49:58and not feel like your values are
50:01are being recognized or In Sync.
50:04What is it? And then what do you what?
50:06What might you be able to do with that?
50:09The other thing is by by any with
50:12qualitative work and longitudinal too,
50:14the more you can sort of hold
50:16anchor it in theory.
50:19Faculty agency is all over the literature
50:21and that that is that is generalizable.
50:24That idea of faculty agency is generalizable.
50:27My particular findings know and they
50:29they won't be and they can't be and I'm
50:32not going to pretend they will ever be.
50:40Thank you. Sure. So let me just
50:42sort of wrap up quickly here with
50:46this last this is the
50:49paper I was talking about.
50:50There's a queue I. QR code oh,
50:53longitudinal qualitative research
50:55and meta time to conceptualize time.
50:58This is has has a number of references.
51:02It's not a how, it's not intended
51:04to be a how to do it paper.
51:06But it it does have some practice pearls
51:09in it which I have here collecting data
51:12recursively which we've already talked
51:14about analyzing data in three strands.
51:17So what you what you don't
51:19want to you mean you could do.
51:21You know, I could analyze date and say
51:22this is where the group is at time one,
51:24this is where the group is at time 2.
51:27But that's like a series of
51:30cross-sectional studies.
51:31And that's fine,
51:32but we don't live life in
51:34paragraphs and in cross sections.
51:36We live it in our past bring we
51:40bring our past into our present.
51:42Our present pushes us into the future.
51:44So again,
51:45that longitudinal through
51:47time is what qualitative.
51:49Longitudinal work can do addressing
51:52this idea of mutual reflexivity.
51:54Like it's it's not just I clearly
51:57bring myself to the interviews,
51:59as we all do when we do qualitative
52:01research in in my mind,
52:02like this idea of Co construction.
52:05And it provides a safe space
52:06for the participants of this if
52:09there's mutual we're both learning,
52:11we're both reflecting, we're both growing,
52:13and we're both shaping the this,
52:15shaping each other,
52:16shaping the study.
52:18Using theory is often times helpful.
52:22The one caveat being that most of
52:25the theories that we use are very
52:27like point in time and so sometimes
52:31having to go to more of the world
52:33of sociology where you or something
52:35where has a what has a flow in it,
52:38has movement,
52:39a lot of our theories are pretty static
52:44and then making a longterm commitment.
52:47I talked in the beginning about
52:50this being slow research.
52:54It's slow. It's slow going.
52:59But again, I I think the the reason I
53:02do it is because there are things that
53:04we learn from this kind of work that
53:06you won't you won't really learn cross
53:09sectionally because of that element
53:11of time or you won't learn as well.
53:14The one thing I think I'm working
53:16with my colleague Amico,
53:18and one thing that we're learning
53:20from longitudinal work is that
53:21empathy doesn't really decline.
53:25I would say what we when we
53:27follow people through time,
53:28it definitely changes.
53:31But understanding who they were,
53:33where they are, what they're going
53:35through as they go through medical school,
53:37it's hard to say for us that it declines.
53:40We can certainly say that it changes.
53:43And so that's something that I
53:44picked up and some of my work
53:46that she's picking up now.
53:48So that would be pretty.
53:50I think it's always fairly revolutionary
53:52to push back on some of that more
53:56quantitative survey cross-sectional
53:58data around empathy declining.
54:01So we'll see maybe that that that's the
54:04power of the longitudinal work right there.
54:06But I see we're almost at
54:09the top of the hour,
54:10but I'm certainly open
54:12to any other questions.
54:13Comments
54:18I last one I I love the idea of doing
54:20longitudinal qualitative research
54:21and we're trying to embed it into
54:24some of our intimate partner violence
54:26work as I've talked to you about.
54:28But just wanted to talk about sort
54:30of have you had any challenges with
54:31like either funding for this kind
54:33of work or even publishing sort of
54:35work that's based on such small
54:37numbers of you know even though it's
54:39sort of large amounts of time but.
54:42Potentially a very, very small sample size.
54:44Yeah it it sure there are there are
54:46challenges I mean I think maybe 80 you
54:48could speak to this too like I didn't
54:53a lot of the work that I do the certain
54:55that the the study that with the medical
54:58students that was at Columbia this study
55:00in the Masters program sort of taken
55:02under the guise of program evaluation.
55:05So getting some funding source
55:07sort of start that.
55:09Asking some program evaluation
55:11questions in the you know,
55:13shut off the tape,
55:14ask the program evaluation questions,
55:15get the information you need.
55:17And so dovetailing it is is
55:20probably the the best way.
55:22I know Lizzy in Dundee has gotten
55:26some major funding around COVID
55:29and Doctors Wellness and COVID.
55:33And so that was that was there,
55:34but it was like a six month sort
55:36of emergency blast and then
55:37they got another six months.
55:38So sometimes if you're going for funding
55:41it could be a little piece meal.
55:43But again you're you don't have to do a
55:46longitudinal study for three years if you're,
55:48you know, make it, make it, make it doable.
55:51And the same thing with numbers,
55:53you got to make it doable because if you're,
55:58you know,
55:58you start out with an end of you know, 15.
56:02Your third round,
56:03you're already up to almost 50 interviews,
56:05and that's a lot.
56:07That's a lot. So yeah,
56:09we've got to get over the numbers thing.
56:12And.
56:13And and yes, yes, it is an issue.
56:16What I've tried to always do in writing
56:18is to say, yeah, I had six people,
56:2012 years,
56:2280 interviews.
56:23Thank you.
56:26Yeah, you do it and then
56:28you can criticize me.
56:29But what's one of the reasons
56:30why I'm writing a book?
56:30Because I can no longer.
56:32I can no longer get this that what?
56:36What if I want to tell the bigger picture?
56:39I can't do it in 3000 words, and I'm.
56:42I'm tired of chunking it up into writing only
56:45a little piece or picking only a few people.
56:48So it's it's it's it is what it is.
56:51It's forcing me out of of academic
56:54writing and into creative nonfiction.
56:58That's great, but that's me.
57:02Thank you so much.
57:03This this is amazing to me.
57:05Thank you. Thank you.
57:06What an example of agency,
57:08right? Yeah.
57:11You got to do. Yep.
57:12Yep. And I get it.
57:13It's if I say anything,
57:15you know, the idea of story.
57:17So even if you're interested in
57:18thinking of or doing longitudinal work,
57:21just keep in the back of your mind
57:23this idea of narrative analysis and
57:25keeping the story story together.
57:29That can be really powerful. Stuff. So
57:35thank you so much.
57:36Enjoy the rest of your day.
57:38Thanks for having me.
57:39Thank you so much. Story. Absolutely.
57:43I'll be in touch. All right.