What Dylan Graetz, MD, MPH, found after examining four decades of failed efforts to treat adolescent girls with anemia in the slums of Mumbai taught her a critical lesson: Sometimes evidence-based medicine driven by hard data alone can miss the target entirely.

Graetz had spent 2 years designing a mixed-methods study — one with both quantitative (numbers and statistics) and qualitative (narrative) data — and trying to imagine every possibility: thalassemias (blood disorders), nutritional deficiencies, religious ideas, or even gender inequalities such as females eating last. As she would soon learn, none of these were right.

First, the team interviewed the girls’ mothers. “They all said, ‘We’re trying to feed them, but they won’t eat,’” Graetz recalled. So they interviewed the girls, who said, “The way out of the slum is to get married. And the way to get married is to be skinny.” The girls were skipping meals to lose weight.

Self-restriction was not on anyone’s bingo card. “All of the solutions were addressing the wrong problem,” said Graetz, now a pediatric oncologist and researcher at St. Jude Children’s Research Hospital in Memphis, Tennessee.

The research goal pivoted to better understanding the girls’ behavior. Findings revealed that Hollywood and Bollywood body types had shaped perceptions that normal BMIs were overweight. “Since there are few healthy choices available in this community, ‘dieting’ is often synonymous with skipping meals,” the researchers concluded. “This phenomenon needs to be identified in low- and middle-income countries.”

The mystery might never have been solved if not for qualitative research.

Qualitative research is the yin to quantitative’s yang — though historically, the balance has been off. Many clinicians see qualitative research as less rigorous or less important. Qualitative studies are also harder to find — less than 2% of subspecialty papers published in the past quarter century were qualitative. That’s finally changing, with big journals such as The Lancet publishing more qualitative research, the World Health Organization vowing to incorporate it more into guidelines, and a growing emphasis in medicine on patient-centered care.

“If you’re just looking at big data sets, you’re only getting part of the story,” Graetz said. “You’re missing the ability to understand context and individuals.”

Just Talking to Your Patients Isn’t Enough

Here’s a sign you need more qualitative research in your practice: You feel like you don’t have enough time with patients.

“Clinicians are caught in a system that does not afford them the time to sink into inquiry, hold space, listen deeply, or be uninvested as a fixer in what you’re hearing,” said Rachel Grob, PhD, director of the Qualitative and Health Experiences Research Laboratory at the University of Wisconsin-Madison.

Qualitative study participants tend to confide more, Grob said, particularly when they perceive the act as helping others like them. Occasionally they report feeling like they are unburdening themselves.

“It’s a different positionality that opens up a different space,” Grob said.

That applies to physician participants too. In one recent study, researchers interviewed 20 nephrologists to find out why hospice is underutilized for patients with end-stage kidney disease. They found that many believed hospice and dialysis were mutually exclusive — that patients had to stop dialysis before starting hospice. The nephrologists also were unsure when to recommend patients for hospice care and felt that neither kidney doctors nor hospice teams were adequately prepared to provide such care. The researchers proposed better training for nephrologists to know when to recommend hospice care and how to work with hospice teams.

The historical foundation of evidence-based medicine recognizes the importance of qualitative work. Even Archie Cochrane, MB, BCh — one of the founders of evidence-based medicine — referenced qualitative research when he discussed how to derive meaning from evidence, said Barbara Bokhour, PhD, professor of preventive and behavioral medicine at the University of Massachusetts Chan Medical School in Worcester.

“Quantitative research can get you a breadth of understanding,” Bokhour said. “What qualitative allows you to do is have a depth of understanding.” That can help you have more productive conversations with patients.

One of Bokhour’s projects involved focus groups designed to explore men’s experience with sexuality after prostate cancer treatment. Her analysis identified four quality-of-life domains: qualities of sexual intimacy, everyday interactions with women, sexual imagining and fantasy life, and men’s perceptions of their masculinity. A key finding was how erectile problems affected men not just in their intimate relationships, but also in their lives outside of intimacy.

Months later, the journal editor who had written an accompanying editorial approached Bokhour at a conference.

“He said, ‘You know, just personally, I want to let you know that I now really think of it differently when I sit down and talk to my patients about the treatment and possibility of sexual dysfunction,’” recalled Bokhour.

Ultimately, your knowledge of your patients’ lives and values is key to leveraging qualitative research to improve clinical practice.

“Qualitative research is by nature not generalizable because it dives deep,” Graetz said. “But it is transferable.”

Where to Find Qualitative Research — and How to Use It

If you’re just reading the big journals, you probably won’t find much qualitative research. Some blame concerns about rigor, but there’s also a space issue: The big mastheads limit manuscripts to 2500 words, which is cramped for research based on data that is, essentially, quotes.

Here’s a plan for rebalancing your research diet to include a little more qualitative input:

Set a goal. Commit to reading one qualitative paper a month (they can be long). For physician-scientists, find a qualitative research buddy and consider adding an exploratory phase up front, Graetz suggested.

Look in these journals: Journal of General Internal Medicine, Annals of Internal Medicine, Medical Care, and the family of The Lancet journals (which recently published a new qualitative series). It’s also a reasonable approach, Bokhour said, to simply search your specialty or area of interest and the term “qualitative” in PubMed. Grob also suggested looking to books, rather than journals, because the long format allows more room to present findings and evidence.

Check your bias. A study that sparks a strong reaction may signal a learning opportunity. Perhaps you reject the ideas because you think the evidence isn’t credible, or you embrace them because they resonate with your experience. “Try to find a middle pathway,” Grob suggested.

Derive meaning. Read the stories to reconnect you to what Graetz calls the “heart and humanity of medicine,” and then dig into the tables. That’s where qualitative researchers present meaningful patterns and “the depth in the words of the people who gave them to us.”

Connect that meaning to your patients. Use the “reinforcing humanity in healthcare” philosophy, developed by an international group of healthcare communication experts led by Gregory Makoul, PhD, MS, communication scientist at Yale School of Medicine, New Haven, Connecticut:

• Connect as humans: Ask patients and caregivers about their perspectives on issues, problems, and solutions.
• Focus on understanding: Listen (and make a conscientious effort to focus more on what they are saying than on what you will say or do in response). Makoul suggested physicians try not to talk for 1 minute.
• Be responsive: Shape plans together and take goals and abilities (both yours and theirs) into account.

The experts cited in this article reported having no relevant disclosures.