Dear Chris & Paul
It strikes me that there are some interesting parallels between the needs of
a general practitioner and those of a nurse when it comes to research
applicable to practice. From my own experience as a patient presenting to a
GP, the information elicited in relates as much to the my explication of the
meanings/experience of feeling unwell as to signs and symptoms of a disease.
This is probably why qualitative research can be so useful to general
practice. This is exactly the reason it has been important to nursing.
But I am unsure quite what Chris means by 'intrinsic' research
methodologies; my dictionary (OED) states that intrinsic means inherent,
essential or naturally belonging to. This suggests ownership, rather than
the concept of 'useful to' which I suspect is what Chris is getting at. But
this might just be my propensity for hair splitting.
Perhaps more pertinent is the issue of matching research method to the
question at hand. Paul's hierarchy is useful, but raises the question of how
do you match a particular qualitative methodology to a descriptive question.
To some extent the qualitative methodology is intimately tied to the
investigator rather than the type of data being collected, and with some ie
phenomenology, the investigator is largely the method. The
credibility/trustworthiness of the data is a function of how closely the
investigator has matched their method to that of the ontology and
epistemology of the methodology used (methodology meaning the philospohical
assumptions underpinning the approach and the method meaning the way in
which the data is collected/analysed). It seems to me the only way to deal
with this (and would love to hear of alternatives) is to split qualitative
questions into those generally requiring inductive and those generally
requiring deductive groups. An inductive question might well use
methodologies such as phenomenology (in its various guises) or hermeneutics
or ethnography; a deductive question might well use a grounded theory
approach (I am aware I am treading on very shaky ground here).
Thus 'what are the phenomena/problems?' suggests identifying the key/core
phenomena and is focused on deductive methodologies. Perhaps another way of
putting this so that it includes the inductive is 'what are the
phenomena/problems and/or the meaning(s) of the phenomena to patients?'
But I might be hair splitting again
Kind regards
Andrew Jull
Clinical Nurse Consultant
Auckland Hospital
Private Bag 92024
Auckland
NEW ZEALAND
Phone: +64 9 3797440
Fax:+64 9 3072818 (external)
7718 (internal)
> -----Original Message-----
> From: Paul Glasziou [SMTP:[log in to unmask]]
> Sent: Thursday, 9 December 1999 09:52
> To: Chris Ellis
> Cc: [log in to unmask]; [log in to unmask]
> Subject: Re: Numbers in medical research
>
> Dear Chris,
> Your unhappy patients have a familiar ring, and its great your researching
>
> this. Thoroughly investigated series of patients with a particular
> complaint often turn up no identifiable cause (my estimate from a few
> series is about 30%). What is going on? Our ignorance is probably much
> larger than most of us realize, and there is much to be discovered. The
> method of inquiry will depend on the question. My current classification
> of
> questions and appropriate study types is below (I'd be interested in
> variants of this). I currently put your unhappy patients in category 1 -
> we
> just don't know much about the phenomena. But when you've found out more
> several of the other categories of question will become important (what
> happens to these people? Can we alter the problem? etc) and then you'll
> need larger numbers.
>
> 1. What are the phenomena/problems?
> Observation (e.g., qualitative research)
> 2. What is frequency of the problem? (FREQUENCY)
> Random (or consecutive) sample
> 3. Who has the problem? (DIAGNOSIS)
> Random (or consecutive) sample with Gold Standard
> 4. Who will get the problem? (PREDICTION)
> Follow-up of inception cohort
> 5. How can we alleviate the problem? (INTERVENTION)
> Randomised controlled trial
>
> Best wishes,
> Paul Glasziou
>
> At 03:47 PM 9/12/99 , Chris Ellis wrote:
> >Mark Gabbay's question arises so often that I think we should perhaps
> >readdress it as case histories and their significance, power, validation,
> >place in the hierarchy of research and their extrapolatability (if I may
> >use such a word) where discussed on this list about 18 months ago.
> > This is also covered in some new textbooks which other members will be
> >able to give to Mark.
> >
> >My interest is a parallel one of using small numbers in research (not the
> N
> >of 1 thing) which has also be discussed in this forum before.
> >Several years ago I completed a doctorate in family medicine\general
> >practice. My thesis was that a few patients were coming in to see me who
> >we as doctors were packaging in to boxes such as anxiety neurosis,
> >depression, personality disorder, somatisation disorder etc etc. I felt
> >they were unhappy so we researched the phenomenon of Unhappiness (ref.Can
> >Fam Physician 1996:42:645-651).
> > Only 4 patients in my practice fitted our selection criteria
> reasonably
> >uniformly. The only appropriate research methodology to investigate this
> >condition was the purely qualitative method of existential phenomenology.
> >My promoters who included a professor of research psychology and a senior
> >research philosopher spent over 200 hours over 3 years discussing and
> >teaching me the method.
> >Whilst we were doing the verification\validation\trustworthiness via the
> >standard qualitative processes we were continually questioned by those we
> >submitted it to for triangulation\explosion\free imaginative variation
> etc
> >with the question, How can you do research with only 4 patients? (And
> what
> >the dickens is existential phenomenology?).
> >
> >Which brings me, rather long windedly, to my point about small numbers in
> >medical research and case histories (or clinical biographies or patient
> >stories or several other similar texts that are used as research
> >information).
> >Parkinson described only 6 cases of his eponymous disease from his
> practice
> >in Shoreditch in London in his original description (Parkinson J. An
> Essay
> >on the Shaking Palsy. Sherwood, Neely and Jones, 1817).
> >The Argyll Robertson Pupil was described initially in one case (Argyll
> >Robertson D. On an interesting series of eye symptoms in a case of spinal
> >disease. Edinburgh Medical Journal 1869; 14:696-708).
> >(By the way if anyone else has examples of similar small series from
> >practice could they let me know, as I am building up my case)
> >And this brings me to my real and final point (at last) which is that I
> am
> >keen on trying to keep general practice research within my practice. As
> >soon as I leave it and go into the general practice unit at the medical
> >school I seem to have the living reality of myself and my practice
> removed.
> > My patient's relatives, the receptionist's background whispered
> >information, my partner's comments in the tea room (the so called rich or
> >thick texts) are removed and I am told I must have a trillion cases and
> >something called statistical significance (I am numerically challenged).
> >I am trying to write a post doctoral monograph which I have tentatively
> >called :
> >In Search of an Intrinsic General Practice Research Methodology.
> >Could anyone help me with advice? This may have already been covered
> >before.
> >Yours
> >Dr Chris Ellis
> >29 Oriel Road, Pietermaritzburg, KwaZulu\Natal, South Africa.
> >Fax 033-3868400. Tel : 033-3869208. E mail : [log in to unmask]
>
> Paul Glasziou
> Harvard Centre for Risk Analysis
> 718 Huntington Avenue, E-221
> Boston, MA 02115
> Fax: 1-617-432-0190 ph: 1-617-4320095
>
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