R.H. Ellaway is professor, Department of Community Health Sciences, and director, Office of Health and Medical Education Scholarship, University of Calgary, Calgary, Alberta, Canada. A. Kehoe is a research associate, School of Medical Education, Newcastle University, Newcastle-upon-Tyne, United Kingdom. J. Illing is professor of medical education research, School of Medical Education, Newcastle University, Newcastle-upon-Tyne, United Kingdom.
Acad Med. 2020 Jul;95(7):984-988. doi: 10.1097/ACM.0000000000003232.
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 posits that the social world is real, that it exists independent of our knowledge of it, and that it is driven by causal mechanisms. However, unlike postpositivism, a realist epistemological position is that our understanding of the mechanisms that underlay social reality is limited and subjective. Critical realism is focused on understanding the mechanisms that drive social reality even when they are not directly observable. 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?" To that end, realist inquiry explores the mechanisms that drive social systems and the ways in which these mechanisms work to develop explanatory theories of the phenomena under consideration. Although, compared with other approaches, realist inquiry is relatively new in medical education, the value of realist inquiry is in its ability to model how complex interventions function differently across multiple contexts, explaining what works, how it works, for whom, and in what contexts.
理解复杂干预措施，如医学教育中的干预措施，需要一种能够解释事物在不同背景下如何以及为何起作用或不起作用的科学哲学。批判实在论及其在实在论探究形式中的具体化提供了这种解释力。本体论上，批判实在论假设社会世界是真实的，它独立于我们对它的认识而存在，并且它是由因果机制驱动的。然而，与后实证主义不同，实在论的认识论立场是，我们对构成社会现实的机制的理解是有限的和主观的。批判实在论专注于理解驱动社会现实的机制，即使这些机制无法直接观察到。批判实在论范式中最常用的方法之一是实在论探究，它侧重于背景、机制和结果之间的关系。其实质是，实在论探究关注的是“在什么情况下，对谁，如何，为什么有效？”为此，实在论探究探讨了驱动社会系统的机制以及这些机制如何发挥作用，以形成所考虑现象的解释性理论。尽管与其他方法相比，实在论探究在医学教育中相对较新，但它的价值在于其能够模拟复杂干预措施在多个背景下如何以不同的方式发挥作用，解释什么有效，如何有效，对谁有效，以及在什么背景下有效。
