For some time now, I have been contemplating the kinds of questions we ask in health professions education (HPE). These ruminations began in 2010 when I was working on a paper about my medical school’s efforts to implement an educational innovation. Truth be told, I had a real problem. My study was supposed to be an evaluation of the innovation’s implementation; however, the data highlighted all the workarounds we constructed to make the innovation fit within our contextual constraints. How could I evaluate our implementation of the innovation when I was no longer confident that what we had implemented was still an exemplar of the original innovation?I found myself asking questions like: Why do we value this innovation? Why is our implementation an example of the innovation at work? How much can I change the innovation before I turn it into something else?

I started searching the literature to find insights into these questions. Surely other HPE scholars have had similar concerns. Surely I would not be the first to venture down this rabbit hole. Right

Unfortunately, I could not find the answers I was looking for in the literature.

 I reached out to one of my mentors, Dr. Glenn Regehr, to ask him my questions and to report on my unproductive literature search. Glenn, in his forward and deep thinking ways, had already thought about this conundrum and was about to publish a paper that started to address these issues.  He also generously helped me think through my data and my interpretations—work that resulted in, what remains to this day, one of my favorite publications (despite it being one of my least cited works).

But this still has not stopped me from thinking about the questions we ask in HPE, nor about that unproductive literature search. As a field, we tend to focus on how questions: How did you implement the innovation? How did you construct the exam for the medical students? How did you prepare them for practice? How did the residents learn in the workplace?

I care more about why questions: Why does the innovation work? Why did you construct the exam this way? Why were the learners ready for practice? Why did the resident learn in the clinical pace? I can do something with answers to why questions. I want to understand the philosophies, principles and premises that underpin what we do in HPE. With that understanding, I can engage in generalizable work, in translating findings to new contexts, and in applying what I’ve learned to completely different phenomena.

I am a researcher who likes to think about these why questions, but my clinician colleagues often need more immediate answers to how questions. Therein lies the conundrum; we need both how and why questions. This tension had me thinking linearly, with why questions at one end of a continuum and how questions at the other. But that did not sit well with me. A continuum is too simple. It doesn’t ring true for the complexities that abound in the body of HPE research literature. But if how and why questions are not ends of a continuum, how do they relate to each other? Can they both provide valuable insights into individual phenomena?

For years these questions rattled around in the back of my brain as I worked on other topics. But, to my great fortune, I recently had the opportunity to work with three keenly intelligent PhD trained scholars working in HPE—Dr. Dorene Balmer, Dr. Meredith Young, and Dr. Kori LaDonna) as part of the Research in Medical Education (RIME) committee at the Association of American Medical Colleges (AAMC). Together, we reflected on the questions we ask in HPE. And what they say is true: two heads are better than one, and four is just a treat (well, that’s not quite the saying, but it should be).

We realized that, for HPE to be a generative and viable field of inquiry, we need both why and how questions because they offer different perspectives on the study of individual phenomena. We need both kinds of questions to be asked and answered so that we can comprehensively understand the phenomena that inform our practices. If I think back to my innovation dilemma, I needed to know why and how it worked in our context. Together, Dorene, Meredith, Kori, and I wrote another of my favorite papers on this very topic.

This brings me back to my original 2010 rabbit hole: Why are there so many how studies in the pages of our journals and far fewer why studies. My hypothesis is disappointing: I think we favor how studies because they’re easier to do. How questions are often descriptive. Why questions are often explanatory. It is easier to describe a phenomenon than to explain the inner workings of a phenomenon. But easier does not mean less important. We need both how and why studies. They are both important. But why is a harder rabbit to catch.

This brings me to the point I want to make: Scholars in HPE need to do the hard work of wrestling with why questions. When you complete the literature review into your phenomenon of choice, look and see what kinds of questions are being studied. Are they predominantly addressing how questions? Can you find studies asking why questions? If you see a paucity of why questions, I urge you to take on the challenge of chasing those questions and seeing just how far down the rabbit hole goes.


Did you know that the Harvard Macy Institute Community Blog has had more than 175 posts? Previous blog posts have explored topics including designing better surveys for education and research, self-efficacy, awareness, disclosure, and reflection, and unconscious bias.


Lara Varpio

Lara Varpio, PhD, is a Professor of Medicine and Associate Director of research for the degree programs in health professions education at Uniformed Services University of the Health Sciences. Lara’s areas of professional interest include research methods / methodologies, health professions education research units, and interprofessional collaboration. Lara can be followed on Twitter.