You are reviewing the selections process for prospective students to your residency program. You explore whether there is evidence to guide the current approach used at your program, and you wish to know what other factors influence current practice locally and elsewhere, and how and why these practices developed.
Critical Discourse Analysis
Why Discourses Matter
Medical education practices are social phenomena. The field of medical education research continues to grow, producing evidence to aid in our understanding of educational practices. However, as with any social phenomena, our education practices are shaped by dominant social discourses. That is to say that contemporary social and cultural values and representations of truth play a large part in the development, evolution, and justification of educational practices. Hodges (2017) points out that the admissions criteria of the late 19th century, excluding women as “’totally unfit’ to practice medicine” are obviously rooted in the dominant social norms of the time. Today’s approaches to candidate selection are less blatantly inequitable, but this education practice is still governed by social discourses.
Critical discourse analysis (CDA) is used by researchers to explore seemingly taken-for-granted truths. This research methodology focuses on language at a macro-level, to identify what it is possible to say, who is allowed to speak, who is silenced, and the underlying power relationships. Using this approach researchers can discover how ‘truths’ about a certain topic are constructed at particular times and in particular places. CDA allows researchers to rigorously interrogate claims of truth in medical education; beyond simply identifying that some practices are based in tradition rather than evidence, researchers can determine which traditions lead to the current practices, how, and why (i.e. to whose benefit). In doing so, we open up opportunities for scholarship, reappraisal of common practices, and change (Kuper, Whitehead, and Hodges, 2013).
For the question posed here, a CDA can provide a useful lens for an analysis of selection processes. The first step is to define and delimit an archive of texts to analyze. An initial project might be limited to an examination of internal documents regarding selections criteria or internal/external accreditation documents concerning admissions. Contextual features of these texts, including authorship and publication status (public or private) are key data in addition to the content. A researcher could also consider interviewing the program director, selection committee members, and applicant interviewers and file reviewers. A key strength of CDA methodologies is the ability to integrate multiple complementary sources of data.
Theory is Central
CDA is a methodology deeply embedded in theory. Prospective researchers using these methods who don’t have a background in critical social theory should consider engaging with scholars in other disciplines to support the theoretical foundation of their research. The centrality of theory can be seen by some as a barrier to conducting and consuming this kind of research, especially for physicians whose previous experiences with research are in positivist, experimental domains. For the same reasons, communicating the importance and relevance of the findings of CDAs remains a challenge.
How To CDA
This discussion of CDA addresses the methodology (the over-arching research approach) rather than the method (the techniques of data collection and analysis) in part because there are no prescriptive guidelines. Common features to CDA approaches include the creation of a dataset of texts (academic and non-academic texts, interview transcripts, visual materials) delimited by time, place, authorship, etc. and textual analysis using a theoretical framework. Exploring different applications of CDA in medical education research can illustrate the various approaches used (see annotated references). For example, a Foucauldian CDA examines historical moments of change in discourses; therefore, the archive of texts is generally temporally defined and the analysis is historically centred.
Key Learning Points:
- Medical education practices are socially constructed practices governed by social discourses
- CDA can be used to explore taken-for-granted truths whose social construction may be hard to appreciate without stepping outside socially dominant discourses
- Because CDA involves familiarity with critical social theory, involving social scientists may be necessary for researchers new to this methodology
- Hodges B.D. Rattling minds: The power of discourse analysis in a post-truth world. Medical Education 2017;51:235-237. In the context of contemporary cultural discussions of ‘post-truth’ and ‘fake news,’ Hodges highlights the utility and necessity of examining socially constructed truths in this accessible commentary which provides the rationale for conducting rigorous discourse analyses in medical education.
- Kuper A., Whitehead C., & Hodges B.D. Looking back to move forward: Using history, discourse and text in medical education research: AMEE guide no. 73. Medical Teacher 2013;35:e849-e860. This AMEE Guide is a thorough introduction for medical educators and education researchers interested in reading and producing research using critical discourse analysis. This paper is framed around the concept of ‘making strange’ or viewing practices accepted as ‘normal’ as the social constructs that they are.
- Razack S., Hodges B., Steinert Y., & Maguire M. Seeking inclusion in an exclusive process: Discourses of medical school student selection. Medical Education 2015;49:36-47. In this paper, the authors engage with several powerful social theories and employ different methods of data collection to critically examine the tensions between excellence and equity in medical student selection. This research exemplifies the capacity of CDA to identify and critique concepts in medical education that are taken for granted, here meritocratic student selection.
- Haddara W., & Lingard L. Are we all on the same page? A discourse analysis of interprofessional collaboration. Academic Medicine 2013;88:1509-1515. The authors focussed on academic literature to conduct a Foucauldian CDA of the concept of interprofessional collaboration, identifying two major and competing discourses.