Author
Anton J. Kuzel, MD, MHPE
Professor of Family Medicine
Mixed methods in health services research:
Doing what comes naturally to clinicians
Virginia Commonwealth University
Presenter
Steven H. Woolf, MD, MPH
Professor of Family Medicine, Preventive Medicine and
Community Health
Virginia Commonwealth University
Executive Vice President for Policy Development,
Partnership for Prevention
AcademyHealth Meeting
June 8, 2004
San Diego, California
Two classic ways of knowing in
clinical medicine
Goals of this talk
„
„
„
Briefly describe how clinicians appear to
effortlessly use at least two basic “ways of
knowing”
knowing” in caring for their patients
Summarize typical reasons for using “mixed
methods”
methods” in health services research, and
suggest analogies in the clinical enterprise
Illustrate a simple application of “mixed
methods”
methods” in a recent study of medical errors in
primary health care
Two classic ways of knowing in
clinical medicine
„
“Subjectifying”
Subjectifying”
„ Patient
as maker of meaning
for action that is dependent
upon patient’
patient’s conscious behavior
„ Appropriate
„
“Objectifying”
Objectifying”
„ Patient
as “body machine”
machine”
for action that is not dependent
upon patient’
patient’s conscious behavior
„ Appropriate
“Body machine”
machine” model has validity
„
„
„
Similar anatomy and physiology among humans
is foundational for much of Western medicine
Western medicine can reduce suffering and
prolong life, hence “body machine”
machine” appears
ethical
Skillful clinicians know that there is more to it
than this
1
“Maker of meaning” model
„
„
Most clearly needed when task is behavior
change (e.g., taking medicines, stopping
smoking)
“Transtheoretical”
Transtheoretical” model of behavior change
requires particularized understanding of the
meaning of current and imagined future
behavior
Integration of the two models
„
„
„
„
Analogies with “mixed methods”
research
„
„
At least five typical reasons for using “mixed
methods”
methods” in health services research
Each has an analogy in clinical medicine, in
which the objective and subjective models are
integrated
1. Instrument creation
„
„
2. Triangulation
„
„
Research: Looking at something using more
than one way of knowing, or more than one
viewpoint
Clinical analogy: Hypertension as a result of
disordered regulatory mechanisms (clinician
view); hypertension as a result of too much
stress (patient view)
Explanatory models of signs or symptoms
Hypertension as a disorder of vascular and fluid
regulatory mechanisms (body machine model)
Hypertension as a literal translation (too much
tension – maker of meaning model)
Skillful clinician respects patient model and
works to “coco-create”
create” the meaning of the
hypertension
Research: Making quantitative tools using
qualitative methods
Clinical analogy: Clinical inventories (e.g.,
depression screening instruments) were initially
developed by observations and interviews
3. Data transformation
„
„
„
Research: Initial qualitative analysis of data to
develop codes, then using descriptive statistics
to describe how often they are observed
Clinical analogy: Astute clinicians recognize
patterns in their everyday experience, and apply
quantitative data to help characterize patterns,
suggest path of investigation
Illustration from our work
2
Harms Reported by Patients
4. Explanatory model
„
Economic
7%
Anger and related emotions
34%
„
Personal worth
11%
Physical
23%
Relationship effects
10%
Psychological
70%
Research: Qualitative data and analysis are used
to explain quantitative data (e.g., patterns in the
data, or the meaning of outliers)
Clinical analogy: Blood pressure logs show
elevations on Mondays – eventually found to be
result of weekend binge drinking
Anxiety about health
6%
Opportunity costs
7%
Other emotions
2%
Source: Kuzel et al.
5. “Nested” design
„
„
Research: Both quantitative and qualitative
questions are asked and answered in the same
study using appropriate methods
Clinical analogy: What is the efficacy of a new
blood pressure medication, and what is the
patient’
patient’s experience of taking the new medicine?
Coming full circle
„
„
„
A pragmatist will employ values, beliefs, and
methods that seem likely to result in desired
consequences.
Adhering to a narrow set of options reduces the
possibilities for positive action.
As Borkan suggests, we should embrace
numbers and narratives (Ann Fam Med 2004;2:42004;2:4-6)
References for typology of mixed
methods models in primary care
research
„
„
Cresswell JW, Fetters MD, Ivankova NV.
Designing a mixed methods study in primary
care. Ann Fam Med 2004;2:72004;2:7-12
Stange KC, Zyzanski SJ. Integrating qualitative
and quantitative research methods. Fam Med
1989;21:4481989;21:448-451.
3