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Acad Med. 2020 Feb 25. doi: 10.1097/ACM.0000000000003232. [Epub ahead of print]

Critical Realism and Realist Inquiry in Medical Education.

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R.H. Ellaway is professor in the Department of Community Health Sciences and Director of the Office of Health and Medical Education Scholarship, University of Calgary, Alberta, Canada. A. Kehoe is a research associate in the School of Medical Education, Newcastle University, Newcastle-upon-Tyne, UK. J. Illing is professor of medical education research in the School of Medical Education, Newcastle University, Newcastle-upon-Tyne, UK.


Understanding complex interventions, such as in medical education, requires a philosophy of science that can explain how and why things work, or fail to work, in different contexts. Critical realism and its operationalization in the form of realist inquiry provides this explanatory power. Ontologically, critical realism reflects the post-positivist philosophy, that the social world is real and independent of our knowledge of it, but that it is driven by causal mechanisms. However, unlike post-positivism, the epistemological position is subjective, reflecting that our understanding of the mechanisms within social reality are limited and subjective. Critical realism is focused on understanding the mechanisms that drive social reality. One of the most commonly used methodologies in the critical realist paradigm is realist inquiry, which focuses on the relationships between context, mechanisms, and outcomes. At its core, realist inquiry is concerned with "What works for whom, under what circumstances, how, and why?" Critical realism, like other philosophies of science, sets out a particular worldview, in this case that the world is real and is driven by mechanisms that may function differently according to context. Realist science focuses on exploring these mechanisms and the way they work, in order to develop explanatory theories of the phenomena under consideration. Although, compared to other approaches, realist inquiry is relatively new in medical education, the value of realist inquiry becomes particularly apparent when it is used to model how interventions work across multiple contexts, using complex interventions to explain what works and how it works, for whom, and in what contexts.

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