Why is qualitative interdisciplinary research so difficult to take seriously?

I was recently corresponding with a professor discussing one of the “Big Five” medical journals. My research is primarily qualitative and he remarked that the particular editor he was talking to, “doesn’t believe that qualitative research is research.” It is unfortunate that this perception exists in academic medicine and in particular with journal editors, the gatekeepers of scientific knowledge. I’d like to address the arguably widespread perception in academia that interdisciplinary research is generally of poor quality and more specifically, challenges that qualitative research faces in academic medicine. In order to answer this question, I thought it was necessary to address a more fundamental question: What is the definition of quality and who defines it?

Any scientific exploration must include an understanding of the research’s epistemological framework. Those with a realist ontology seek an objective truth that exists independently of an individual’s understanding of the world, whereas qualitative researchers tend towards a more interpretive lens.

The challenge with interdisciplinary research is that it operates at the intersection of these different theoretical frameworks. Researchers are thus confronted by the debates between these diverse worldviews in ways that disciplinarily focused researchers are not. Due to unequal funding streams and leadership structures, dominant frameworks emerge within interdisciplinary departments, which dictate definitions of quality.

Because publication counts factor so highly in evaluation metrics such as the REF, the academic publishing industry has a tremendous influence on this interdisciplinary research agenda. A drive to publish in high impact journals incentivises researchers to conform to these journal’s definitions of quality, even if their definition reflects a framework that is different from their researcher’s mode of inquiry.

Traditional quantitative medical sciences for example, judge research quality by its generalizability and validity. Because of this, they are less accepting of approaches such as phenomenology, which focus instead on understanding the subjective experiences of individuals in a specific setting. Checklists have emerged to conform qualitative research to positivist understandings of validity and generalizability. Standards such as double coding to ensure objectivity and consistency, are required for publication in reputable medical journals. One checklist even recommends that “interpretation must be grounded in ‘accounts’ and semi-quantified if possible or appropriate.”

I have spoken to social scientists working in medical based departments, who felt that the need to adapt to the principal discipline posed challenges to their intellectual self-identity. They expressed angst over their inability to produce research true to their home discipline’s definition of quality. This might affect their own employment prospects if they decide to move back into their native discipline. In my own research, I have realized that manuscripts I will submit to medical journals will need to written through a more objectivist mindset, rather than through an interpretive framework that seems more appropriate for my project.

This perception of poor quality reflects not only intrinsic prejudices against interdisciplinary research, but also systematically ingrained biases in the publication process. A recent study elucidated factors that contribute to this perception by showing that journal rankings inherently disadvantaged this type of research. They found that top journals “span a less diverse set of disciplines than lower ranked journals,” resulting in systematic bias against interdisciplinary research. Because publications in high impact journals are a proxy for quality and determine REF evaluation and financing, this becomes a disincentive against engaging in interdisciplinary research.

Many have warned me that it is difficult to publish qualitative research in the best medical journals. Particularly discouraging is a study which showed that over a span of ten years, only 0-0.6% of articles in the top ten medical journals were qualitative. As an early career researcher, this means that I will have a more difficult time distinguishing myself amongst my quantitative colleagues, since evaluation for jobs, promotions, and funding, are primarily based upon where we have published.

This is also disheartening if one thinks about the real world impact of requiring interdisciplinary research to conform to sweeping definitions of quality (impact is after all a REF priority!). These overwhelming structural incentives promote further siloing into individual disciplinary camps. As a medic transitioning into the social sciences, I have been thoroughly impressed by the ability of social scientists to provide a deeper understanding into key problems in health care. Social scientific inquiry in medicine has the potential to apply alternative insights towards positively informing health care practice. Cross-fertilization of ideas will remain limited unless we redefine quality to include all relevant modes of inquiry, and lower the barriers to publishing interdisciplinary research.


Bringing emotions back into medicine

I had always thought I could never be a great doctor because I felt too emotionally bound to my patients. It was impossible for me to hold back tears when feeling that gut wrenching empathy for families mourning the passing of their loved ones. Because it always seemed as if I were the only resident moved by these scenes, I reasoned that this was an unprofessional impulse that prevented me from being the calm, scientific, quick thinking doctor that exemplified the model physician.

This perception is so exalted in medicine, that it was the motto of my medical school’s residency program: Aequaminitas. Based on an essay of that title by Sir William Osler, it means unperturbability. They urged us to become that ideal doctor who had that, “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness.” It was these doctors who had the expertise to heal their patients, not ones who were so “weak” as to weep with a patient during life and death situations.

My last day of residency was my most memorable. I was rotating on the intensive care unit where a 21-year-old Mexican immigrant boy was dying of end stage testicular cancer that had spread throughout his body. His stomach was swollen from liver failure, he was in a deep coma from insults to his brain, and infection had spread throughout his blood and body. For days, we struggled to keep him alive — tethered to life support, with virtually every organ maintained through artificial means. He was the sole breadwinner of his large family, and they were completely unprepared to let him go. His mother threatened to kill herself if her son died, and his brother begged to me every day to let him donate half his liver to his sibling.

He died during rounds on my last day. Seared into my mind was the image of his mother throwing herself onto the floor and hitting her hands and head on the floor, howling with sorrow. His father swept their daughter into his arms and ran out of the ICU with unbridled angst.

Every doctor in the room stood there watching in silence. I tried with all my might to control my tears. Blinking frequently. Thinking about hard medical facts. Staring at the ceiling. But it was not possible, so I quickly excused myself to run into the supply closet to weep in private. When I returned, rounds went on as if nothing had happened.

A recently essay by David Bornstein, “Medicine’s Search for Meaning” resonated tremendously and brought these memories back to the fore. In it, he describes the need for a culture change within medicine to embrace emotions and provide compassionate care. His article and others have noted how a lack of humanism in medicine contributes to burnout and low physician satisfaction. Disillusioned physicians who initially pursued medical careers to connect with and help people, instead find themselves in a health care infrastructure dominated by bureaucracy and little time for patient interactions.

In order for programs such as the Healer’s Art, to counter the dehumanizing aspects of medicine in a physician’s professional life course, they must consider expanding to residency. Residency is the time when young doctors experience for the first time that terrifying sense of responsibility for making life and death decisions in the middle of the night, and having to tell a parent that their child has died.

These unforgettable experiences are watershed events in a doctor’s life, as they are the moments where their actions directly impact patients, rather than in medical school where they are chiefly the apprentice watching it being done. I had taken the Healer’s Art in medical school, but by the time residency rolled around there was little opportunity to circle back and reflect upon those lessons.

There is little time and space in the harried life of an intern to think about these sorts of things. Non-clinical time is packed with curricular essentials on the fundamentals of medicine. Yes, it is critical that a doctor understand how to treat high blood pressure and manage liver failure. But as the article stated, it is arguably as important to the therapeutic relationship to cultivate caring doctors who not only feel compassion, but also feel comfortable expressing it.

Perhaps more importantly, creating no-judgment spaces for dialogue amongst residents allows for mutual understandings of common experiences, which in my experience was completely alien in residency. I had always felt like there was something wrong with me for feeling emotions. I felt like everyone around me had a confidence and assurance that I never had, and did not experience the self-doubt I did when patients did poorly. Only upon reading Bornstein’s article did I realize that I might not be alone.

This article was originally published on 28 October 2013 on KevinMD.com

How Much are Misaligned Incentives in Health Care Costing Tax Payers?

On Christmas Eve, I took care of a patient who had just undergone surgery for an infected artificial shoulder. He was to be discharged on intravenous antibiotics three times a day for six weeks. This is a pretty common treatment. Patients are generally able to give themselves this medication with the help of a home care nurse who visits once a week. The total cost of this is approximately $7000 for nursing visits, antibiotics and supplies ($120 per visit for eight nursing visits plus $143 per day for antibiotics)

The social worker informed him that Medicare would not pay for home care nurse visits or supplies. BUT, Medicare pays for inpatient rehabilitation, which he would be eligible for to receive these antibiotics. Given the choice of paying $7000 for home administration versus $0 for inpatient rehabilitation, naturally he chose inpatient rehabilitation.

The problem is, is that his inpatient stay costs taxpayers approximately $21,000. $350 for room and board plus additional costs for antibiotics and supplies, totaling approximately $500 a day. Furthermore, although he was well enough to be discharged home before Christmas, he needed to stay until he could be placed in rehab. Because of holiday scheduling, most rehabilitation facilities were not accepting admissions. Thus, he had to stay in the hospital an extra four days in the hospital over the weekend and holidays. Given that the average cost of a hospital stay is $2338 in Maryland that added an additional $9352 or so of unnecessary expenses.

In sum, because financial incentives encouraged my patient to spend $0 rather than $7000 out of pocket, Medicare spent an unnecessary added $30,000 on his hospitalization and care.
To make matters worse, my patient didn’t even want to go to rehabilitation. He preferred to administer the antibiotics himself at home and found it hugely inconvenience to have to be an inpatient for six weeks just for antibiotics. He was a small business owner, and these extra days in rehabilitation would hinder his productivity at work. He was upset that he had to stay in the hospital over the holidays for unnecessary reasons. He was upset about this twisted logic, which forced him to choose the less resource efficient option and lamented the financial burden he was unwillingly imposing on taxpayers.

This decision would harm my patient in other ways. Medicare limits beneficiaries to sixty lifetime days of inpatient rehabilitation care, so if he ever needed future inpatient care, he would have fewer days available to him. Staying in a hospital facility can also be harmful medically, as added days in the health care setting place him at increased risk for health care acquired infections.

The United States has been in recession for years and calls for fiscal responsibility ring loudly. Fiscal crises and congressional deadlock have almost become the new normal. Rising health care costs account for 25% of total federal spending and stands at $2.8 trillion a year. This contributes a significant portion of our national debt at a time when we can’t afford wasteful spending.

The Affordable Care Act has attempted to curtail waste through various mechanismsincluding redirecting care from high cost specialists to lower cost primary care doctors, restructuring reimbursement from fee for service to a value based model. Others have suggested various cost cutting mechanisms such as reducing overtreatment, implement market-based incentives, and reduce overhead.

My patient’s situation illustrates another aspect of potential cost control that has not frequently been discussed. Skewed financial incentives caused by illogical Medical reimbursement schemes create additional unnecessary costs that are not just wasteful, but also harmful and inconvenient to patients. $30,000 is a great deal of money to waste on something that is medically unnecessary and unwanted.

This is but one example where misaligned incentives drive providers and patients to choose the less efficient, more wasteful option. Examples are abound in health care. Patients in New York regularly told me that they called an ambulance because it was cheaper to them (free!) than a $20 cab ride. An ambulance ride in New York City costs $704 per ride not including mileage. Medicare and Medicaid contribute approximately half of the FDNY’s total revenue of $205 million yearly.

I remember referring one of my clinic patients to the social worker because she had recovered from depression and wanted to get a job. The social worker discouraged her from finding employment and instead advised her to volunteer because she would lose her disability benefits if she found gainful employment.

Because uninsured patients do not have outpatient drug coverage, it is not uncommon for uninsured cancer patients to be admitted to the hospital in order to get outpatient chemotherapy infusions. This adds approximately $2338, the average cost of an overnight admission, on top of what would have been an outpatient infusion.

I could go on and on.

Policy changes that systematically reform these misaligned incentives could do much to reduce illogical decisions that cause wasteful healthcare spending. Lobbying and patchwork legislation have led to our current system of fragmented reimbursement schemes where benefits initially meant to help patients, create unintended consequences leading to wasteful spending. Long-term solutions to counteract our increasing federal deficit require bending the cost curve of health care. Taking a careful look at Medicare reimbursements that don’t make sense could potentially save millions of health care dollars and improve quality of care.

Special thanks to Donald List, LCSW-C, for assisting with obtaining the costs of the therapies and services mentioned in this article.

Originally published on thehealthcareblog.com on February 23, 2013