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Family Practice© Oxford University Press 1996 Vol. 13, Suppl. 1Printed in Great Britain

Qualitative research: the research questions it canhelp answer, the methods it uses, the assumptionsbehind the research questions and what influencesthe direction of research.A summary of the panel discussion at theconference Exploring qualitative research ingeneral practiceFrances GriffithsThis pape r describes the themes identified by the editorfrom the recording and transcripts of the panel discus-sion at the conference Exploring qualitative researchin general practice. The editing process was a form ofqualitative analysis in itself The panel discussion wasbased on research questions developed by groups of con-ference participants during the conference lunch b reak.The research questions were selected for discussion bythe panel chairman and panel members. The panel con-sisted of the conference speakers (DA, SH, MJ, CH,RJ) and chairman (MM) with other conference par-ticipants contributing comments (one contributor couldnot be identified from the recording). In this paper thediscussion points made are attributed to the personspeaking by initials following their comment. The textdoes not represent exact quotations but the editor hasendeavoured to preserve the essence and meaning ofthe comments (FG).One criterion used in the selection of topics for discu s-sion was w hether the group of participants had produceda question. T he panel decided to respond only to ques-tions. We are programmed to look at research asquestions but is research only about questions? (SH).

Research questions that qualitativemethods can help answerQualitative methods may provide useful tools forunderstanding phenomenon for which, at present, wehave no really good working models, for example, whypeople do not take prescribed drugs as intended by thedoctor (MM ). 'Wh y' questions such as W hy do GPsnot implement evidence-based guid elines? are best ap-

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proached with a qualitative method (DA), but 'what'ques t ions such as W ha t a re evidence-basedguid elines? may also use qualitative methods (SH).People may say that evidence-based guidelines are agood thing but act differently. To start making senseof that we need to ask doctors 'What do you mean byevid enc e? The behaviour of GPs may be based mo reon the evidence of their own expe rience which is a dif-ferent notion of evidence from that used in guidelines(CH ). A research question such as W ha t precipitatespeople to present to their GP saying they are tired allthe tim e? raises other questions: W ha t does tirednessme an? A re people more tired now than they we re?H as the meaning of tiredness ch ang ed ? (SH). Theresearch question W hat does drug-seeking behaviourreally me an ? is a different ord er of question as it istrying to find out what drug-seeking behaviour meansin a particular culture or society, rather like asking W hat does going to church m ea n? It is a sociologicalor anthropological question which cannot be answeredby simply interviewing people. Developing an answerwould involve starting from a particular theoreticalperspective (e.g. Marxism or psychoanalysis) whichmay provide some insights, then finding a way of testingthese out (DA). It is possible ask individuals W hatdoes this mean to yo u? The answers may be expres-sions of the bigger scheme or the individuals may giveinteresting idiosyncratic answers of their own. Theseanswers only make sense against a backgroun d of thethemes in society at the time, and those you have todiscover by looking at the media, analysing newspapers,etc. (CH ). To begin to answer the question D o pa-tients and GPs both want the same thing out of generalpra ctic e? , the.different m eanings and assumptions oftwo grou ps in society, doctors and patients, would haveto be investigated . The question indicates the clash oftwo cultures but we do not know enough about them,it would be complex to investigate and the question asphrased is probably too big to get started (CH).

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Family Practice—an international journalMethods used in qualitative researchA resea rch qu estion can be looked at from differentangles and using different methods to provide differenttypes of answer. This notion of triangulation can resultin stronger and better research tools (MM). The dif-ferent methods may be qualitative, quantitative or a mix-ture . A po pulation survey may reveal the frequency ofa symptom such as tiredness and how many peopleconsult their doctor about it. To understand why som epeople go to see their doctor and others do not, someof those that attend the doctor and some that do not couldbe interviewed (RJ).

An interview study can take many forms. O ne of thecommonest used is the semi-structured interview wherethe interviewer h as a schedule of areas to cover. Inter-views of do ctors about evidence-based guidelines mayinc lude H av e you heard of evidence-basedguid elines? D o you know what in your clinical prac-tice is based on evi den ce? D o you apply guidelines,when and wh ere ? (DA ). However, if the interviewsubjects are GPs, can a GP be the interviewer? Oneview is that you cannot study your own tribe becausethere is too much hidden culture and assumptions. Th eresearcher needs to ask innocent questions to uncoverthis. H owev er, there can be good and bad interviewersfrom all disciplines, it is partly a question of techni-que. A GP interviewing GPs will give a different in-terview and get a different story from a social scientistinterviewer, but who is to say that one story is goingto be more interesting or rewarding than the other?(CH) .

There are specific techniques that can be used withininterviews to enhance the research data. For example,a research q uestion about b eing tired all the time is using,what is know as standardized language of distress. Allof life's problems from unemployment to marital prob-lems come in the phrase 'tired all the time'. To workoutward s from this label you could use free-association,asking question such as ' 'W hat do you mean by tired?''' 'W hat do you mean by all the time? ''Wh at do peoplewho are not tired look like ? When looking at any con-dition it can be very revealing to ask about the exactoppo site. If you ask someone taking diazepam W hateffect does diazepam have on you when you take it?the reply may be O h it does not have any effect .Asking W ha t would happen if you did not havedia zep am ? would give a different series of answ ers.A different technique could b e used for a research ques-tion, such as W ha t are the images which GP s haveof themselves and their role s? If you ask a doctor' 'H ow do you see your ro le? they are likely to freezeup as the question is so open-ended. One way aroundthis would be using projective techniques. You couldgive them a series of scenarios , each one a descriptionof what a G P do es, and ask them which they most iden-tify with, or give them a story of a GP and ask themto tell you about the doctor written about in the story.

This way the person interviewed can be more relaxedas they are not talking about them selves but projectingonto the story (CH). Interviews have to aim at findingout about things that are accessible to the person inter-viewed. If you asked a GP W ha t do you want fromgeneral practice? you might get a public or pat answer,but it would be too general to be of value in the research.The question would have to be broken dow n as you canonly find out what people can make sense of themselves(DA).A group interview could be used to develop, for ex-ample, a list of priorities for quality standards in generalpractice. The results from a group of GPs and a groupof patients could be compared to see how much theymatch (RJ). A Balint group is a special form of groupresearch which could look at when and why doctorsfollow evidence-based guidelines or not, and tease outsome of the detail of this. Being from a differentdiscipline, the psychoanalyst in the Balint group has theimportant role of heightening perception and observa-tion to help the group see what is at that moment beyondthe field of vision (SH).

Observational studies can reveal the reality behindthe rhetoric. For exam ple a research question about theprimary health care team may see the team as a groupof professionals co-operating with each other. However,the members of the team come from a number of dif-ferent professional subcu ltures. It w ould be interestingto do a flynon-the-wall observation to see how thingsactually worked (CH).Written material has been mentioned as a source ofdata about the prevailing c ulture. In trying to answ era research question such as 'What does tiredness mean?'in a literate society, looking at printed material suchas newspapers and wo men 's m agazines is important inrevealing the wider cultural themes. Doing this revealsa who le series of so-called d epletion diseases based onmechanical metaphor such as 'running on empty' 'ata low ebb' 'drained' (CH). The historical study of aquestion about a symptom such as tiredness may usea series of medical texts, of which th ere are many fromthe eighteenth century on ward s. A historian m ight lookat the way words are used in certain contexts such asfatigue, as used by a psychiatrist or a pathologist.Newspapers and personal diaries or correspondence,if available, can also be used. However, historians arewary of seeing continuity in the use of, for example,

diagnoses over time. To use the example of learningdifficulties, historians would argue that it is difficultto be sure whether a diagnosis based on a number ofsymptoms made in the nineteenth century, such asfeeble-mindedness, is the sam e as wha t we are talkingabout now in terms of learning difficulties (MJ).Health diaries have been used in the past to researchillness behaviour but were dropped because ofmethodological difficulties. Patients would no t completethem as they claimed they made them feel ill (DA).

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Qualitative research; a discussionRecently they have been used successfully in conjunc-tion with interviews for looking at help-seekingbehaviour. The diaries acted as an aide memoir in theinterviews, a blank entry sometimes reminding theperson interviewed of what happened that day, such asa child falling out of a tree (?). A variation on thismethod is to ask people, for example, those that saythey are 'tired all the time', to write a story about howthey came to be tired all the time (CH). This methodhas also been used therapeutically (PC). In the eight-eenth century a doctor attending a rich patient wouldask the patient to transcribe their own experience andsymptoms. The diagnosis was then negotiated betweenthem, partly as the patient and doctor were consideredequals. This was before what Foucault refers to as thedevelopment of a clinical gaze and the patient becom-ing an object that can be studied (MJ).

The assumptions behind the researchquestionsA research question such as 'Are there limits to skillsubstation in primary care ?' is about nurses taking onnew roles, GPs delegating certain tasks and perhapstaking on other ones. However, there seems to be anagenda here about how different health care workersfeel about changing roles and tasks. The question mayhave started as a statement 'There are limits . . .' (MM ).What does 'limits' mean? D oes it mean 'A re there limitsto potential?' or does it mean 'Who is setting up bar-riers?' The question makes an assumption that there arelimits (SH). Behind the question 'What does drug-seeking behaviour really m ean?' there seems to be anagenda about whether we approve of drug taking or no t.There is a lot of feeling behind the questions we ask,they are not innocent they are knowing and are not somuch questions as statements of a point of view. Allfacts, all data are values. For example, a researchermay have some feelings about evidence-based medicinethat may affect the way in which the researcher setsabout the research. A re we able to distinguish the valuesystem in which we approach these questions and thetype of research we do? (MM)A historian, if asked a question such as 'Why didmortality rates change in the twentieth century' wouldwant to ask further questions, such as, 'Did theychange ?' 'W here does the evidence come from?' 'W hocompiled the statistics?' and 'How and what do theytell us about groups within the population as well asthe whole?' D uring the 1 930s, for example, the rhetoricfrom public health officials and the government wasthat mortality rates were declining and standards of liv-ing were improving, but fairly close historical studyof the figures they quoted suggests that, although in thepopulation as a whole standards of health may have been

improving and mortality rates declining, there were cer-tain sections of the population in certain parts of thecountry who were not benefiting from declining mor-tality rates. By asking 'Why did mortality rates decline?'you are avoiding a whole set of issues about health,medicine and disease in society (MJ).

Influences on the direction of ourresearchA researcher's experience and background will in-fluence the way a research project develops; however,a much greater constraint on what research questionsare tackled and how, is the availability of funding.Research has to be related to policy and has to be inthe area of interest of the grant-giving bo dies. This con -straint is greater now that the big sums of researchmoney are centrally controlled (RJ). Gran t-giving bodieshelp create the culture that shapes the whole researchenterprise and , in a sense, it has been ever thu s. Majorparadigms capture the research m arket for long periodsof time (MM). The challenge is to get involved withthe policy development of these grant-giving bodies(RJ).A problem for researchers, particularly in health ser-vice research, is that the questions w e ask chan ge beforewe answer them. There is a move towards research forquick decision-making where, rather than seeking aglobal answer to a research question, we do a short,focused, non-generalizable project, often with a mix-ture of research methods, to answer a specific healthservice problem. This process may emerge in the futureas an important research paradigm and with this formof research the issues about generalizability w ould ceaseto matter (RJ).The research question about the use of evidence-basedguidelines leads to a historical question about whyevidence-based medicine has becom e so prominent now(RB). The basic medical sciences that emerged fromthe late nineteenth century have made a dramatic dif-ference to diagnosis and treatment of certain medicalcondition s, and this is part of their legitimating pow er.This medical science is perceived by doctors and pa-tients and, until the last 10 -20 year s, w as perceived bythe media as a major contribution to society. How ever,some of this optimism is beginning to dissolve, and partof this process is the challenge made by the legal pro-fession, through law suits, and by the media, to thecultural supremacy of medical science. One of thereasons why experimentalism, bio-genetics, bio-reduction is so potent now is because it is a reactionto some of that criticism and to those external forcestrying to undermine the practice of medicine. Historianswould see this process as a series of negotiations withthe professional groups and different interests constantlyshifting position (MJ).

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Family Practice—an international journalOur training as doctors has led us to trust experimentalresults or results of research based on large populationsamples and to lose our trust of our own perceptionsand experiences. The word 'anecdotal' has become asort of swear wor d, y et what is wrong with anecdotes?Some of the g reatest breakthroughs in history have beenmade from anecdotes. As GPs and general practice

researchers w e have to develop trust in our own percep-tions and the perceptions of others (CH).

ConclusionQualitative research is not an ultimate pathway to truth ,but it is useful and can reach p arts that other forms ofresearch cannot (C H). At present, qualitative methodsmay be viewed as at the bottom of a hierarchy ofmethods with randomized controlled trials at the top.

Yet in the last 50 years one of the most major changesin health service provision in this country was theclosure of psychiatric hospitals, and one of the keydeterminants of that was a qualitative study (DA).1Whenever you look at the history of research you findthat researchers have suddenly broken through a bar-rier and shown us something which we really did notsee before. The question for m edicine, and in particularfor everyday general practice, is what is staring us inthe face now that we just cannot see. Answering thatquestion seems to be the exciting po ssibility for the kindof research approaches that have been discussed in thisconference (MM).

Reference1 Goffinan E. Asylums Essays on the social situation of mentalpatients and oth r inmates Hannondsw orth: Penguin 1968.

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