What is a Paradigm? Medical Education as a Social Science

Terms like paradigms, ontologies, and epistemologies are difficult to understand. Not only are they jargon-y words, if you've ever tried to search up a definition, you've probably ended up more confused.

Have you ever wondered why? Why should these terms in particular be so difficult to understand but ideas about, say, hypertension are easier to grasp?

It's because these terms:

1. Mostly derive from philosophy and metaphysics, not something most medical education researchers have experience with
2. Deal with abstract ideas like the nature of reality, the nature of knowledge, and how we can obtain knowledge.

Because of these two reasons, we'll have to make some simplifications for the terms to become easier to use.

A simple way to understand these terms is to treat a paradigm as composed of ontology and epistemology (3).

A paradigm is a worldview that defines what in our world is considered real (ontology), and how we can come to understand that it is real (epistemology).

There! A simple straightforward definition for medical education research.

Now let's clearly define each term by itself.

• A paradigm is a worldview, a set of beliefs about what constitutes reality and knowledge, as well as how we construct that knowledge. Therefore a paradigm is the lens through which we view and interpret the world around us. (1)
• An ontology is a viewpoint on what in our world is considered real. When we talk about ontology in the context of medical education research, we're asking fundamental questions like, "What is the nature of physical and social reality?" (2)
• An epistemology is a viewpoint about knowledge itself. It explores questions such as, "What are the origin, nature, and limits of knowledge about reality?" (2)

Let's put these terms into action and see how they're used.

I, like many of you reading this right now, grew up thinking about the world through the lens of biomedical science. I was a biology major in my undergraduate training, and then I went to medical school.

I had no idea at the time, but biomedical science/research actually does have a paradigm with an ontology and epistemology; I just didn’t know it.

The predominant paradigm in biomedical research is positivism.

I don’t know about you, but thinking back to medical school, all of the positivist statements written above were assumed to be true but were never explicitly stated.

When I learned that giving a patient aspirin after a heart attack would have clinical benefits, I accepted it. For me, this was an empirically proven fact. Or, when I learned that insulin and beta agonists can shift potassium into cells, this was something to memorize, not question.

Applying our terms, epistemologically, why did we accept that aspirin after heart attacks had a clinical benefit?

Because we believed that researchers gathered knowledge in an objective and unbiased way. And therefore the resulting truth represented reality. This is positivist!

And ontologically, why did we accept that insulin and beta agonists shift potassium into cells?

Because we believe that there is one tangible reality and what is true for a cellular transporter in one place is true in all places. This is also positivist!

While the positivist paradigm has its merits, it becomes increasingly inadequate when we move into the realm of medical education. Unlike giving aspirin to a heart attack patient or administering insulin to control potassium levels, medical education is not merely a set of biological processes. Rather, it operates as a social science. (5-9)

Let's look at an example: inpatient internal medicine wards, my favorite teaching setting. To my surgical colleagues, I apologize for any boredom-related flashbacks I may have just caused.

Think about what I, as the internal medicine attending, am trying to do in this setting. I have a team full of learners:

• Clerkship students are trying to learn as much as they can while also impressing people who might be evaluating them, while also assimilating cultural norms, while also providing a pair of helping hands.
• Acting interns are trying to do all the same things, but with added patient responsibilities and an eye on the future by contemplating what it will be like in a few months when they have an MD/DO after their name.
• Interns are typically most concerned with just managing their work and providing their patients with excellent care. For many of them, explicit teaching and learning have to take a cognitive backseat to their never-ending list of to-dos.
• Senior residents typically concern themselves with supervising the care of the patients, and ensuring everything goes to plan. But they also carry teaching, learning, mentoring, and cheerleading burdens.
• As the attending, I am worrying about excellent patient care, excellent teaching, being liked by my learners, and ensuring everyone is having fun and avoiding burnout.

Also, we haven’t mentioned differences in identity, power differentials, teaching in front of patients, shame associated with making mistakes, the cognitive load associated with each of the roles and responsibilities, and more.

As you can see, when humans interact, there are far more variables than something as simple as a heart attack (I kid, but not really).

Remembering our insulin example, what's true for one interaction somewhere is definitely not true for all human interactions everywhere!

Constructivism posits that knowledge is not something that is simply transferred from teacher to student but is constructed through interaction and experience.

In the context of medical education, constructivism emphasizes the importance of active learning experiences and social interaction. Students build their understanding through clinical practice, discussions, and reflective processes. Each learner's experience becomes a building block for the shared knowledge of the entire team.

Critical theory in medical education challenges the existing power structures and ideologies within educational settings. It encourages critical thinking about the social, cultural, and political factors that influence education and healthcare delivery.

For example, a critical theory approach may examine how systemic issues such as race, gender, or socio-economic status affect patient care and educational opportunities. Again, there is no one source of truth, as each person experiences power structures and intersectionality differently.

To engage in medical education and to research it, one must accept that what we are trying to study is incredibly complex, and can be tackled from multiple different angles.

Clearly understanding our paradigmatic, ontological, and epistemological view, and being able to explicitly state that to our audiences, is what allows us to study these complex phenomena as an academic community and understand one another.

For additional reading, the journal Academic Medicine has a fantastic series of papers that explores all of this in more depth, and outlines eight of the most common paradigms in medical education. You can find that series here: https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=70