Qualitative research is best characterized as a family of approaches whose goal is understanding the lived experience of persons who share time, space and culture. Although they are often judged as a single entity, the approaches actually vary in their theoretical assumptions and cannons of evidence. Four qualitative research domains that are currently used in studying education for health are reviewed here. They are ethnographic/field work approaches, use of interviews and surveys, audiovisual records, and the study of documents. Characteristics of each domain and brief examples are provided. In addition to introducing the four research domains, we offer some general guidelines on how to be a good consumer of qualitative research. We pose a series of questions about the importance of the research question, study design, and trustworthiness of qualitative research results. In addition, we focus on how research results are presented and discussed. We conclude with the observation that qualitative research approaches are only as good as the questions they set out to illuminate. In the arena of education for health a number of good and important questions remain unaddressed and would benefit by being studied using qualitative research approaches.

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Context: Focus groups are becoming an important method for conducting qualitative research in health care. This strategy enables information to be gathered on the perceptions, beliefs, and values of a group's participants and is particularly well suited to addressing cultural characteristics that impact on a population's health status. As nations become more culturally diverse, qualitative research will likely play a growing role in helping health professions educators develop appropriate educational programs and in helping researchers better understand the needs of minorities and other vulnerable populations who are experiencing disparities in health care. Objectives: The purposes of this paper are to introduce the usefulness of a qualitative research strategy as an adjunct to quantitative survey research, and to describe briefly how researchers and educators at the Charles R. Drew University of Medicine and Science (Drew) have utilized this strategy when conducting combined qualitative and quantitative research. Discussion: Focus group research has been successfully used to develop culturally adapted surveys, to develop educational programs, and to conduct needs assessments at Drew, which serves a culturally diverse urban population.

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In Germany, conducting a research project followed by writing a thesis is necessary to receive the title "Doctor" but is not necessary to work as a physician. To determine the reasons that students abandon their dissertations, we conducted and analyzed a survey among 160 fifth- and sixth-year medical students at the University of Wuerzburg. Fifteen of 160 respondents (9%) reported to have stopped working on their original project before starting their current replacement thesis research project. Among these 15, the major reasons for abandoning the original research project were: seven (47%) reported lack of supervision, three (20%) reported no recognizable progress, and another three (20%) reported an unacceptable burden of work. Unfamiliarity with experimental methods led two students (13%) to stop working on their original research project. Close supervision and a thorough training remain necessary to prevent students from abandoning medical dissertations and thus should be an essential part of every research project in which medical students are involved.

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Background: Medical training traditionally focuses on disease diagnosis and management. The need to incorporate preventive medicine, economics, and health promotion is increasingly apparent. Because problem-based learning (PBL) encourages multidisciplinary thinking, it is ideal for linking traditional medical education and population-oriented training. Although use of PBL has grown in medical education, cases typically focus upon patho-physiology, diagnosis, and therapy of individuals. Even when cases are intended to integrate multidisciplinary topics such as behavioral sciences or prevention, the biological aspects are emphasized. Purpose: To describe approaches to case design that emphasize population perspectives of health. Description: Specific examples drawn from actual cases we have used illustrate how five basic components of a case— namely, title, context, intrigue, indicators of problem resolution, and tight structure— facilitate discussion of, and enhance concern for, population issues. Conclusion: The literature indicates that health professional students tend to favor biological over population content in clinical cases. We illustrate how population content can be represented in speci. cally designed cases.

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Purpose: The Keeping Families Healthy (KFH) program at the University of Florida College of Medicine is a new community-based course designed to improve physician– patient relationships. This paper describes the experience of the first-year medical students' home visits, which were developed to foster health promotion and disease prevention. Approach: This two-semester course offers first-year medical students the opportunity to integrate prevention, service, and humanism into the established educational curriculum. During the course the learners have opportunities to interact with families who have volunteered to serve in partnership with the College of Medicine faculty as community lay teachers. The program provides a valuable service to the participating families by helping them identify useful community resources, and by formulating healthy care plans for prevention of illness and stabilization of chronic illness. Conclusions: Community-based learning and home visits expose students to personal travails (e.g. lack of . nancial resources) in a way that cannot be addressed in traditional settings. This exposure may involve students in community-building strategies that can assist not only individual patients, but also communities. Additionally, home visits provide an opportunity for pre-clinical students to have an active rather than passive role in their education.

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Background: During the 20th century medical education has been preoccupied largely with discussions of the venues and methods for teaching. Little attention has been paid to what should be learned about the scientific paradigm underlying research and practice. A 17th century model has gradually produced a technically efficient but increasingly narrow, monocausal, reductionistic view of health and disease. This "belief system" fails to accommodate or explain the meaning and impact on patients' health of diverse internal and external experiences and in uences. During this period new physics and systemic views of biosystems have extended the Newtonian scientific paradigm beyond its materialistic boundaries, which still determines most of the medical sciences. Methods: A broad range of historical and contemporary scientific literature is examined in support of four central questions addressed in this three-part series: Is there a reason to examine these matters now? How is medical scientific thinking in uenced by the general reorientation of science during the 20th century? Is there is a reason to examine the impact of these changes on medicine now? Will a change of paradigm affect medical practice, research, and education? Results: The extraordinarily productive contemporary biomedical model should be expanded to include meaningful information about how each patient's experiences impinge on health status. Conclusions: Family physicians, together with collaborators in the biological and behavioral sciences and other health professionals, should undertake rigorous research to establish the validity of the expanded paradigm espoused. Its impact could be profound on practice, research, education, and policies.

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Clinical performance is too complex and interactive for measurement. Judgment is always necessary for its assessment. Experienced clinicians judge trainee performance on many small details. This clinical judgment turns on the trainee's handling of important details in the patient and the malady. But the recording of performance retreats to categories and checklists that contain nothing of those critical details or the trainee's judgment. Checklists are incapable of identifying what actually happened, and 'could do' categories have no predictive accuracy in asserting what cases a trainee can actually manage. Clinical examinations have even been subverted by the naive, pseudorational error that competence is de. ned by obedience to doing exactly what someone else expects you to do in every case, as in an OSCE examination. Cases are the unit of clinical practice. The clinical curriculum should be comprised of the critical core cases the trainee must be able to handle in each discipline. Case management, procedural skills and professional behavior can be assessed accurately only in the context of daily clinical work. Formal examinations lack the range of cases and open-ended time that allow examiners to explore a trainee's case knowledge and judgment. Habitual behavior can be assessed only by observing habitual behavior in everyday practice. Assessment and recording should take place only in real world settings, focused on performance on the core cases trainees must be competent to manage.

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This paper outlines a case for a new approach to the education of future professionals. The magnitude and potential seriousness of changes to be anticipated in the first half of the new century challenge institutions of higher education to prepare their students to become able to adapt themselves to change and to participate in the management of change – not only in relation to their own profession, but more widely for the benefit of society at large. The Network of Community-Oriented Educational Institutions for Health Sciences is planning three major programs which are designed to help meet this challenge in the 21st century. The first of these programs will set out to identify generic competencies that are needed for adapting to change and for participating in managing change. This is to include not only profession-specific changes, but also changes that affect the well-being of society as a whole. The second program will address the related need to develop educational interventions that are designed to foster competencies for interprofessional and intersectoral collaboration. The third of these programs accepts that serious attention to effective education for the professions will require institutionalization of recognition and reward of creativity and commitment in education.

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Medical and health professional education needs to renew regularly the perspective from which it defines curriculum. The theme of this paper is that the study of health service in action will identify educational priorities for any country with the particular aim of improving the quality of health care and the effectiveness of clinicians within the system of health care. The Quality of Australian Health Care Study is the largest study of its kind to date. It is a study of adverse outcomes in health care resulting from error. From a study of causes, circumstance and strategies for prevention an educational agenda emerges, dealing both with clinical aspects of care and the less well-documented role of system errors. Studies of system errors in industry and other high risk occupations and systems are now lending insight to issues of error and safety in health care. A new agenda for health professional curriculum is the study of health services in action— the anatomy, physiology and pathology of health systems. Eight educational priorities were recommended to the National Task Force to improve patient safety and quality of care. These are discussed together with a broad strategy for curriculum implementation. The need for a health system that supports and informs practitioners involved in clinical and system errors, the extension of training to incorporate health system managers, and the extension of the consideration of safety to public awareness are discussed.

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Introduction: British undergraduate medical education is undergoing change, including a greater emphasis being placed on community-based teaching. These changes need to be evaluated for their educational outcomes, but there also needs to be a review of the process of introducing change and its subsequent management. The setting: During the academic year 1996/97 a new project was piloted at Leeds University. Fifty-three third year medical students were attached in groups of four to general practitioner tutors in a primary care setting for four days in order to improve consultation skills. There was an emphasis on adopting a patient-centered approach, particularly asking patients about their concerns. Method: These students were asked to .ll in a questionnaire to determine whether the community-based teaching has made any lasting impression on their attitudes and performance. The response rate was 80%. The students commented that even only four days of community-based teaching had helped them realize the importance of asking about patients' concerns. They also reported beginning to concentrate on psychosocial issues while talking to patients, issues that are often ignored by medical students. The students' comments are contrasted with those of the hospital-based tutors, some of whom have looked less than favorably on the project. Discussion: The introduction of any new learning experience needs to be evaluated both in the short term and in the long term. This study begins to address long-term evaluation and suggests that a brief attachment can be memorable to students and beneficial one year later.

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