Learning about general practice through qualitative interviews: Lessons from a seminar course with medical students

Abstract

Background: A seminar course was developed in order to train medical students in qualitative research methods, while providing an introduction to the field of General Practice. Students were enabled to conduct semi-structured interviews with general practitioners (GPs), during which they learned about the prevention, diagnosis, and treatment of frequently encountered medical problems. The course was carried out four times at two universities in Germany.

Aims: The study explores the students’ learning experiences focusing on their research experience.

Methods: Data were collected in four focus groups and analyzed.

Results: The students perceived the course as very different from their usual medical education. This was appreciated, but also caused some difficulties. Three themes emerged: (1) Missing ‘facts’, (2) New horizons: ‘Thinking outside the box’, and (3) The challenge of interpretation: ‘Reading between the lines’.

Conclusions: Learning qualitative research methods can be particularly challenging for medical students as the tasks and epistemology of qualitative research run counter to the usual learning formats and research paradigms in medical education. When teaching qualitative research, special care should be taken to address the cognitive dissonance experienced by students and to explain the unique contribution of qualitative research to medical practice and the field of General Practice especially.

Background

Training in qualitative social science research methods is a valuable contribution to medical education, in particular with respect to General Practice. Qualitative research methods are increasingly being applied in General Practice and family medicine, contributing to a better understanding of the social aspects of health and health care. These include communication between patients, medical providers and caregivers, and their perspectives and views on their diagnosis and treatment (e.g. Pope & Mays 1995; Coleman 2000; Chew-Graham et al. 2002; Jaye 2002; Pope et al. 2002; McKeown et al. 2003; Miller & Pinnington 2003; Parry et al. 2004; Pilnick & Coleman 2006). Qualitative interviewing, focus groups, video-based analysis, and other methods of qualitative data collection and analysis have been increasingly used in General Practice in Germany since the 1990s, often with the aim of improving the quality of primary health care (Bahrs et al. 1996; Brockmann et al. 2004; Sielk et al. 2004; Bahrs 2005; Wilm 2005). In medical education, however, training in social science research methods only plays a minor role, and qualitative methods in particular are hardly ever part of medical curricula, with few exceptions.

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Practice points

Increasingly, qualitative social science research methods, such as qualitative interviews, focus groups, and video-based analysis are being used to improve the quality of primary health care. Training in qualitative research methods improves communication and research skills and constitutes a valuable contribution to medical education, especially for General Practice. Learning qualitative research methods can be particularly challenging for medical students as the tasks and underlying epistemological basis of qualitative research run counter to the usual learning formats and research paradigm in medical education. When teaching qualitative research methods, special care should be taken to address the potential difficulties of medical students and explain the special contributions of qualitative research to medical practice and the field of General Practice especially.

For medical students, training in qualitative social science research methods may benefit their research and communication skills and improve their (self-) reflection as both students and practitioners. For General Practice, integrating qualitative research methods into the medical curriculum also has a strategic aim. By improving the research skills of medical students who will later become general practitioners (GPs), the scientific competencies of this field are strengthened. This is particularly important in Germany where General Practice has only recently become more established as academic discipline (Herrmann et al. 2007).

The seminar course

A seminar course was developed in order to train medical students in qualitative research methods, while providing an introduction to the field of General Practice (Lorenz et al. 2007). The course aimed to (1) develop medical students’ research skills (focusing on qualitative interviewing); while (2) introducing them to the field of General Practice; and (3) encouraging critical thinking and initiative in learning. To achieve these goals, the seminar utilized a learning-by-doing approach (Rifkin & Hartley 2001). The course was restricted to fewer than 20 students per semester as is recommended for qualitative research training in general (Flick & Bauer 2004). In the seminar course, the students first familiarized themselves with frequently encountered medical problems in General Practice and the respective guidelines for diagnosis, prevention and treatment of the German Association of General Practice and Family Medicine (DEGAM)1. Secondly, the students investigated how these guidelines compare with the actual attitudes, practices and experiences of GPs using a qualitative interviewing technique. Each student conducted a semi-structured interview with a GP in her or his practice and presented the findings in class. In the discussions in class, critical thinking and possible alternative interpretations of research findings were encouraged and explored. Class assignments included:

1. Oral presentation of a DEGAM guideline on the diagnosis, prevention and treatment of a frequently encountered medical problem in General Practice.

2. Developing a research question and an interview guide for a semi-structured interview.

3. Recruiting a GP as an interview partner.

4. Conducting, transcribing, and analyzing a 30–60 min semi-structured interview.

5. Oral presentation of the interview experience.

6. Written report about the research project (5–10 pages).

The seminar was an elective class for third, fourth, and fifth year medical students. The course was conducted four times at two universities in Germany (in Halle and Magdeburg). Between 6 and 16 medical students attended each course. Classes took place for 3 h per week for 12–16 weeks.

Methods

At the end of each semester, the students were invited to participate in a voluntary focus group evaluation. Focus groups are an established method of medical education research (Vermeire et al. 2002; Barbour 2005). In this study, focus groups were used to collect feedback from the medical students about their learning and research experience. Four focus groups were conducted, each lasting approximately 60 min, involving 6–12 students. The students were encouraged to outline their views and experiences of the seminar course. The focus group discussions were audiotaped and transcribed verbatim. In one case, the technical equipment was malfunctioning and field notes were written instead. The data analysis focuses on the three focus groups of which verbatim transcriptions could be obtained.

A ‘reconstructive approach’ to qualitative data analysis called ‘documentary analysis’ for group discussions was applied (Bohnsack 2004, 2007). This approach involves four main steps: First, transcripts are coded for content (i.e. the literal meaning of what was said). Second, the group interactions and discourse organizations are reconstructed (i.e. how the topics were framed and dealt within the group discussions). Third, emerging themes are compared and contrasted within and between the group discussions, focusing on those sequences where a topic was discussed in great detail (‘metaphorical density’) or with a high degree of interaction (‘interactive density’). Last, types or patterns are identified (‘collective orientations’). The current analysis focused on how the students described and evaluated their experiences of learning about qualitative research methods.

To increase the quality and trustworthiness of the findings, the following measures were taken: (1) The data were analyzed by a team of lecturers and researchers and further critical feedback from colleagues was sought; (2) during the analysis, the data was searched for ‘negative cases’ that would contradict the emerging themes and explanations; and (3) the researchers practiced critical self-reflexivity throughout the research process to reduce the possible bias and negative effects of their involvement and role as lecturers and researchers (Mays & Pope 2000).

Results

In the focus groups, the students provided appreciative as well as critical feedback. In each group, a range of meanings and evaluations were discussed. All students agreed that the seminar course was highly ‘unusual’ in group size, topics, tasks, and learning style. Some students considered this enriching and useful whilst for others it caused insecurities, boredom, frustration, and irritation. The following three themes emerged in the data analysis, each theme highlighting to some degree a combination of positive and negative aspects of the experiences noted above: (1) Missing ‘facts’; (2) New horizons: ‘Thinking outside the box’; and (3) ‘Reading between the lines’ and the challenge of interpretation.

Missing ‘facts’

When asked about their course experience, the students agreed that it was very different from other seminar courses. One focus group described these differences as follows:

P1: This group is a bit more quote-unquote familial… In the other seminars, I do pay more attention to not making any mistakes, but … here I was also able to pay attention to how I talk.

P4: I believe the size of the group really makes a difference. …

M1: What kind of difference does it make?

P1: [In other seminars] it's not 5 people listening, it's 25. And, well, the topics are completely different. Here, it's possible to bring in a lot of personal judgment. That's the main difference. In the other seminars, we really deal with facts. There I cannot say ‘Yes, but I feel that (inhales deeply), I don’t know, that this bacterium actually leads to this and that, to such and such disease, that's my feeling and not at all what's written in the book.’ (group laughs) So, well, that's how it is. You’re tied to the facts2

The quotation shows that with its smaller group size and supportive learning environment, the course offers opportunities for students to improve their communication and presentation skills and to interact with less fear of making ‘mistakes’. Yet on the other hand, the seminar course did neither fit their expectations nor the standard learning format of their medical education. The topics were ‘completely different’ as the course introduced social science research methods and focused on the bio-psycho-social aspects of health care in General Practice. When learning about qualitative research methods, they were asked to question their assumptions and (critically) reflect on the influence they had had on the interview interaction and the data analysis. They also realized that different interpretations of the same interview data are possible. For many students, this was an unsettling experience. In the above quotation, the ironic statement of student P1 (which caused the group to laugh in agreement) illustrates that he viewed the different role of subjectivity in the research process as risky: An overemphasis on ‘personal judgment’ and ‘feelings’ may potentially lead to false conclusions, such as an imagined relationship between a ‘bacterium’ and a ‘disease’. If a practitioner only assumes (‘feels’) that a relationship exists which is ‘not in the textbooks’, i.e. not proven to be ‘true’, she or he might make a serious mistake when diagnosing and treating patients. Here, the stress, fears and insecurities of the students who are eager to become a responsible medical practitioner emerged as an important subtext. Also it became clear that the specific role of the researcher's subjectivity in qualitative research was not fully understood and was perceived in negative terms only. When this student described being ‘tied to the facts’ in other seminars, he implied it was more reassuring since he could rely on what he considers to be indisputable, ‘true’ ‘facts, i.e. text-book medical knowledge with proven evidence of cause-and-effect-relationships (e.g. a disease is caused by a bacterium).

This lack of ‘facts’ and the underlying assumption that knowledge should be true or false, right or wrong, was also described by other students. In another focus group, a student discussed her interview experience which she considered a failure as it lacked probing on her part or any in-depth discussion. The student concluded that she was simply not the ‘type’ for qualitative research: ‘And that's why this is not for me. Well, for me it's strenuous and I prefer [P2 interrupts: Facts] yes, I like my test tubes better. I put them up and they turn green or blue.’

Qualitative research brings with it a very different approach to investigating and understanding reality: This student expressed a desire for unequivocal findings which may be achieved with test tube experiments in the laboratory, but hardly ever in qualitative research with human subjects in the field. However, it is also noticeable that in this case, the preference of ‘facts’ is expressed while coming to terms with a sense of having failed in terms of conducting a good qualitative interview.

New horizons: ‘Thinking outside the box’

The seminar course encouraged initiative in learning, critical thinking and questioning. While the students, quoted above, missed the transmission of knowledge as ‘facts’, other students appreciated the different approach to learning and knowledge acquisition. When asked about the positive and negative aspects of their seminar experience, one student explained:

P1: And positive, really simply that there exists something like qualitative research and the practical experience of doing an interview. It's a bit like thinking outside the box [‘über den Tellerrand schauen’, literally: to look beyond the rim of one's plate] … approaching the study subject from a different angle … it's a nice change … to be able to work on something more independently and not simply having a lot of information to memorize. …

M1: I’d like to hear a bit more about that. In your studies, you have so many things to learn, learning like facts to memorize, reproduce and apply. That's something quite different from the critical reflexivity we’ve been trying to encourage, right? What was that like for you?

P2: That was good. It made us move our brain cells in different directions … It was a change and it was work also, a different kind of work than we’re used to. May be that's why it was also more stressful. But bottom line, I think, when you’re done with it, it's quite a useful experience.

This student pointed out that the course opened up new horizons for him. He was able to learn more independently and approach medical topics from a different angle. He described his experience in active, bodily terms (e.g. looking, approaching, working, moving brain cells) and stated that these learning activities took an effort. He arrived at a positive conclusion, considering the seminar overall as beneficial (‘nice change’, ‘useful experience’).

‘Reading between the lines’ and the challenge of interpretation

When the student, quoted above, stated his appreciative conclusion, another student felt obliged to defend the usual learning format in their medical education:

P1: [But] it's not simply about dumb memorizing. If you view medicine as a natural science, it IS about facts and not about reading a theoretical sociological text … Sure it's a bit unusual [referring to the qualitative research seminar], but we’re not stupid. And … this is not the main goal of our studies. …

P4: I thought it was good to learn to read a bit between the lines, and not only to kind of learn facts from the textbook. …

P3: I thought so, too, especially when I chose the quotations for the last presentation … I selected these beautiful quotations and then I sat in front of them, asking myself: ‘What did the GP mean to say with THIS?’ That was really a completely different kind of thinking. Not only copying and reading out aloud. It's like you said, we had to think differently again. Yeah, and that was good (laughs).

P5: Well, I don’t know. I don’t think so. To be quite honest, when I did this, I was glad that I study MEDICINE (laughs) and nothing else.

The diversity of opinions is clearly expressed here: P1 argues that learning ‘facts’ is more relevant for their medical education. A female student (P4) disagrees: She appreciates the chance to learn ‘to read between the lines’. Another student (P3) supports this position and illustrates her positive experience of analyzing and interpreting interview data. Her enthusiasm is counteracted by a third student (P5) who takes a very critical stance in claiming that the seminar had nothing to do with medicine.

In each group, some students were highly irritated. This irritation was in part due to unfulfilled expectations and the unusual approach to research and knowledge as described above. Expressions of this irritation were triggered by the high workload of the class assignments and negative experiences with recruitment, interviewing, and data analysis. The assignment of writing a final report was particularly controversial. One student pointed out that she did not understand why they should be writing up something that they had already presented and discussed verbally. Again, the seminar was perceived as different compared to the usual assignments in other seminars. A closer look at the criticism reveals that not only the task of writing, but also in particular the tasks of analyzing and interpreting the data were highly challenging and caused feelings of insecurity, failure, and frustration:

P2: … Ok, I did participate and some of it was fun, but for me this is all somehow too vague … and now writing a report about something that I really did not enjoy at all, is not what I want to do. It's a burden. If it made sense to me, like he said, I wouldn’t mind writing even 20 pages, but that's not the case. I still don’t know what I’m supposed to do with these quotations. In the oral presentation, I kind of pulled something from my sleeve, but I didn’t really understand the background. So that's why it is burdensome for me and I don’t feel like doing it.

The argument of this student is contradictory: Part of the seminar was ‘fun’, but when it came to writing a report, she ‘did not enjoy it at all.’ She expressed that she did not fully grasp the task of analyzing the interview data. For her presentation, she ‘pulled’ quotations almost randomly like a card trick from her ‘sleeve.’ These insecurities regarding the analysis and interpretation were also mirrored by other students who said they ‘did not see the point’ or would not like to ‘read something into it that's not there.’ These students also felt that the class assignments entailed ‘too much work’ and had too little relevance for their medical studies. Some even felt they ‘did not learn enough’ which stands in stark contrast to their feeling of being overwhelmed by some of the tasks. These irritations point to the difficulty of learning qualitative methods of data analysis in the short period of time of one semester. Clearly, the students required more guidance and support in particular with data analysis.

When asked for ideas on how the seminar could be improved, the students suggested that the workload be reduced, a stronger focus be placed on practical medical aspects in General Practice, that more creative teaching and learning methods were applied (such as role play and video analysis) and an alternative advertisement of the seminar so that students know better what to expect.

All focus groups contained positive and negative evaluations. However, a difference between the groups was noticeable in the tone of the discussion and the proportion of appreciative versus negative criticism: For those groups where feedback had been collected early on in the course and adjustments were made, the remaining students identified more strongly with the class and evaluated it more positively, despite the challenges and limitations that were also mentioned. This was the case in the first two focus groups at the universities in Magdeburg and Halle. In the other two cases, the courses had taken place without an early intervention from the students, that is, without a crisis or turning point, and the students voiced their irritation and criticism more strongly in the focus groups at the end of the semesters.

Discussion

The focus groups show that some of the students found the learning experience interesting and enriching. They gained interview skills and improved their communication, presentation and interpretation skills. However, major difficulties and irritations were also expressed. Some of these difficulties resemble the difficulties that other beginners of qualitative research in other disciplines encounter as well, e.g. problems with recruitment, interviewing, and data analysis (Rifkin 2001; Flick et al. 2004; Hermanns 2004). It is also likely that the controversial topic of the interviews (i.e. looking critically at the ‘implementation’ of the DEGAM guidelines by the GP) created special problems for the students and contributed to negative experiences in the field, in particular when a GP felt ‘inspected’ and her or his authority questioned by a student. However, the extent of the students’ irritation and their repeated contrasting of the seminar course with other courses also draw attention to the institutional context in which the teaching and learning took place.

The institutional context of medical education in Germany tends to be characterized by a strong orientation towards the positivist research paradigm of the natural sciences. Against this backdrop, teaching qualitative research methods and introducing a social constructivist research paradigm from the social sciences constitutes a major challenge. The irritation voiced by some of the students may thus be understood as a sign of ‘cognitive dissonance’ (Festinger 1957). In social psychology, ‘cognitive dissonance’ describes a feeling of discomfort caused by holding inconsistent cognitions or by performing an action that is discrepant from one's customary, typically positive self-conception (Aronson et al. 2005). The absence of certainty, the different approach to knowledge and ‘truth’, the new tasks involved in conducting qualitative research, the often encountered sense of failure as well as the experience of being confronted with statements of GPs in the interviews that did not comply with the DEGAM guidelines all posed threats to the positive self-conception of the students. The strong criticism, the distancing (‘I am not the type for this’) and the objection to qualitative research as not relevant for their medical education that was expressed by some of the students can thus also be understood as ways of resolving the tension deriving from their experience of cognitive dissonance.

The fact that students felt free to express their criticism illustrates the good quality of the focus groups data. The students were able to express a variety of opinions and were not limited to socially desirable answers. The above-mentioned differences between the groups (in terms of level of aggression, frustration and critical feedback) imply that it is important to give students the space to voice their concerns and problems during the seminar course. It is important to pay attention to the group interaction and the students’ needs (including the need to deal with the above-described cognitive dissonance). This can be more easily achieved when feedback is invited early on and at different points throughout the course. As stated before, some of the irritation that was experienced and expressed seems unavoidable given the institutional context and the stressful learning situation of the practitioners-to-be (who are longing for unequivocal solid facts to rely on instead of being asked to question and consider alternative interpretations). Also the students’ expectations of science and research are influenced by the dominant biomedical research paradigm that does not usually include qualitative research methods (Albert et al. 2008). As long as this situation persists, a certain level of disappointment and difficulty seem inevitable when introducing qualitative research to the methodical and methodological canon.

Canadian colleagues came to a similar conclusion when stating that teaching qualitative research in the health sciences and medicine means ‘teaching against the grain’ (Eakin & Mykhalovskiy 2005): ‘Although teaching qualitative research (QR) in the health field has much in common with teaching QR in other disciplines and fields of application, the specific institutional location of such teaching has unique and challenging consequences for both those who teach and those who learn.’

Because of these particular challenges, an extra effort needs to be taken to explain not only the differences between qualitative and quantitative research approaches, but also the points of connection and the value of mixed-method studies. It should be highlighted (and illustrated with empirical examples) what can be gained from expanding the traditional methodical and methodological spectrum of medical research. When teaching qualitative research methods in medical education, special care should be taken to explain the contributions of qualitative research to the particular professional field and professional practice. Also the benefits of learning qualitative research skills should be made explicit in order to help the students understand why it might be worthwhile to manage the challenges of the learning experience. For example, it is helpful to illustrate the relevance and benefits of these research skills with examples from the experience of medical practitioners in General Practice. It will thus become more tangible what can be gained from an open, person-centered approach to interacting with patients and caregivers. It will become more clear how qualitative research skills can help GPs understand the various perspectives and what qualitative research studies can add to improving the quality of care.

At the universities of Halle and Magdeburg, the course is no longer conducted in its previous form. A more intensive introduction to qualitative methods and supervision is now offered to medical students who wish to apply qualitative research methods in their dissertation projects. This colloquium is offered in cooperation with other departments and institutes at the medical university who are similarly interested in establishing and integrating qualitative research into medical education. Such cooperation brings the benefits of creating an environment that supports interdisciplinary learning, teaching and research in medical education.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

Hella von Unger

HELLA VON UNGER, PhD, is a social scientist and researcher at the Social Science Research Centre Berlin (WZB), Research Group Public Health, Germany.

Katrin Werwick

KATRIN WERWICK, MA (PhD candidate), is a lecturer and researcher at the Institute of General Practice and Family Medicine, University of Magdeburg, Germany.

Thomas Lichte

THOMAS LICHTE, MD, is a professor of General Practice, director of the Institutes of General Practice and Family Medicine at the Universities of Magdeburg and Halle, Germany.

Markus Herrmann

MARKUS HERRMANN MD, MA, MPH, is a professor of General Practice, director of the Institutes of General Practice and Family Medicine at the Universities of Magdeburg and Halle, Germany.

Notes

1. The German Association of General Practice and Family Medicine (DEGAM) has developed guidelines on the diagnosis, prevention and treatment of frequently encountered medical problems such as ear-ache, back pain, tiredness, stroke, urinary incontinence, elderly patients who are prone to falling, and family care-givers. DEGAM guidelines are available (in German only) from http://www.degam.de/typo/index.php

2. Own translations of the original German transcript into English; Transcription legend: P = Participant(s); M = Moderator; words in capital letters were emphasized.