Clinical Colleague and Clinical Academic: A Physician’s Autoethnographical Reflexive Account of Opportunities and Challenges as an ‘Insider’ Researcher

Abstract

‘Insider’ positionality, where the researcher shares a context with those researched, has been considered in many settings but infrequently by physicians. In this reflexive autoethnographic account, a physician undertaking qualitative methods research exploring shared decision-making in the acute hospital setting describes and critically appraises her experience of studying physician colleagues. She considers each step of the research in turn with reference to her insider positionality which she came to realise was neither absolute nor fixed. Professional experience informed a clinically relevant line of inquiry while the sometimes uncomfortable transition between physician and researcher prompted reflection which added depth to the research question. Being an insider was beneficial in accessing potential participants, but the extent to which the ‘ethnographic toolkit’ of the physician-colleague social position defined recruitment success is discussed. Data collection during semi-structured interviews benefitted from a shared clinical language although this needed to be balanced with avoiding assumptions of shared meaning. There was heightened researcher consciousness of peer scrutiny on questioning the status quo and of workplace hierarchy when interviewing senior colleague ‘elites’. A sense of responsibility to colleagues and tendency to draw on personal clinical experience to make sense of an elusive thematic analysis became apparent during the analysis. The research experience ultimately led to increased confidence with inhabiting a role neither truly insider nor outsider. This critical account contributes to methodological understanding of reflexivity by physician qualitative researchers and seeks to benefit others embarking on a similar journey.

Keywords

insider research positionality autoethnography reflexivity decision-making shared decision-making healthcare communication doctor-patient communication doctor-patient relationship

Introduction

The ‘insider’ position, where the researcher shares a background and/or experience with those researched, has been explored in many contexts including class, community and professional similarities (Chavez, 2008; Drake, 2010; Folkes, 2022). Significance of the insider position is debated. No two experiences are identical and therefore being an ‘insider’ does not equate to complete researcher affinity with participants (Reyes, 2018). Furthermore, all researchers, not just insiders, must be cognisant of their positionality and the complexity this entails. Benefit of being an insider is also not clear-cut. The insider researcher may be able to expedite rapport with participants, commence the research with relevant contextual insights or find greater ease of access to some groups (Chavez, 2008). In some fields, such as emancipatory research with traditionally disempowered groups, the insider viewpoint can be especially important (Ross, 2017). However, an insider perspective might lead the researcher to take some practices for granted, or participants may make assumptions of the researchers’ stance. Negotiating pre-existing relationships can be challenging (Chavez, 2008). Considering these complexities of the insider researcher position, an insider reflexive account presents an opportunity to recount and appraise one’s experience with reference to existing literature. There appear only to be select examples of such accounts from healthcare professionals (Burns et al., 2012; Koopman et al., 2020; Wilson et al., 2022).

Autoethnographies are ‘stories of the self, told through the lens of culture’, which describe and analyse the researcher’s personal research experience (Adams et al., 2015). An important component of autoethnography is reflexivity, a critical evaluation of the researcher’s positionality (core attributes such as gender, class or profession) and how these can impact on the research process and outcome (Berger, 2013) through assumptions, choices and others’ reactions (Braun & Clarke, 2022). Some have argued powerfully that such personal reflexive accounts can be superficial and performative (Macfarlane, 2021) or even run the risk of narcissism (Delamont, 2009). In sharing their accounts, researchers may be exposing themselves to unwelcome scrutiny (Walford, 1998). Many others feel that transparency about a researcher’s experience and recognition of the role of the ‘self’ in knowledge production are important contributions to academic rigor. Counter, perhaps, to early tendencies in sociology research to obscure the role of the researcher, or contemporaneous standards in quantitative methods to demonstrate avoidance of bias, there are numerous articles in qualitative research journals advocating for the role of reflexivity (Berger, 2013).

Qualitative research has not always been well received by traditional medical research communities, even though it promotes ‘new ways of thinking that are essential to scientific progress’ (Greenhalgh et al., 2016). Consequently, there may be a reticence from physician researchers to embark on qualitative research. Furthermore, physicians undertaking research from an insider perspective may encounter specific challenges and consequently benefit from others’ accounts and critical analysis. In this article I consider my role as physician and researcher. I explore the opportunities that being a ‘fellow medic’ brought to my research and reflect on the challenges I perceived transitioning between the clinical colleague and clinical academic role.

The Research Study: Shared Decision-Making in Treatment Escalation Planning

This was a qualitative interview study with physicians about treatment escalation planning (TEP) in hospital with older patients. TEP is widely used in the UK and other settings to decide, in advance of a patient’s deterioration, what interventions would be attempted to preserve life. Current guidance states that shared decision-making (SDM) be employed wherever possible in healthcare decisions in the UK, including in TEP decisions (British Medical Association et al., 2016). From my own clinical experience, previous research activities and literature review (Warner et al., 2023), I was uncertain how much this was practicable and practised. As part of a larger PhD programme of research, which will include further interview studies as well as ethnography, I sought to understand physicians’ perspectives on SDM in TEP. This area of study falls within clinical fields of internal and intensive care medicine, and has health policy and medical education implications.

Having been thinking about these research ideas for several years, I commenced this study in 2022 and completed data collection in early 2023. As part of a team of researchers with clinical and academic backgrounds, I recruited 26 physicians, comprising registrars (qualified doctors completing the final years of their training who often have initial responsibility for TEP decisions) and consultants (most senior doctors) in intensive care, emergency medicine, internal medicine and palliative care. There were 11 female and 15 male participants.

I conducted semi-structured interviews using topic guides. In-depth interviews are a core qualitative research method used to gain insight into individual perspectives by focusing a conversation on the research aim with the flexibility for in-depth exploration of viewpoints. I included three clinical vignettes as an enabling technique to prompt discussion (Ritchie et al., 2013). In brief, participants were asked to describe their approach to TEP, invited to discuss the vignettes and finally directly asked their views on SDM in TEP.

Research ethics committee approval was obtained from the Health Research Authority 22/HRA/4387 and all participants gave me written informed consent in advance of the interview and confirmed their consent again verbally at the beginning of the interview.

Critical Assessment of My Insider Experience

Planning the Project

I started thinking about this project while still working full time clinically, spending much of my time as a medical registrar in a busy Acute Medical Unit in northwest London. It says something perhaps that in this opening sentence I have mentioned simultaneous clinical and academic commitments, northwest London (a competitive location to secure a post) and a busy clinical schedule. Doctors are notorious would-be over-achievers, and, amidst fierce loyalty and collegiality, can stray into competitiveness and one-upmanship. So, unwittingly I have set the scene for my own professional context and outlook. I remember chatting to a clinical colleague about my idea for an interview study with physicians about decision-making in TEP. She said, “What a great idea” but also, “I mean you already know what you’ll find…”. I understood her to imply that (of course) shared decision-making is not practised in treatment escalation planning. On the one hand, our shared background of UK medical training gave us a common understanding that this was inconsistent with guidelines and therefore worthy of exploration, but on the other hinted at a pointlessness in my research. Another medic tendency is to find relatively undemanding opportunities which will lead to much-needed points for the next job application; there is general sympathy with colleagues doing a routine audit to enhance their career but at the same time a veiled disapproval. Is this what she thought I was doing – an easy project to benefit my CV?

Without realising it, I was already encountering challenges associated with being an insider researcher. I had set out to explore physicians’ perspectives on a decision-making process, but, as a physician myself, colleagues might perceive this exercise to be futile as I already knew how things worked. And if this was the case, was the purpose of documenting their perspectives at best self-advancing and at worst a means to make judgemental, overly simplistic, newspaper headline-worthy conclusions about their practice? I realised the need to think more critically about my research question and aims. It wasn’t enough to ask, ‘are we doing SDM?’ I needed to leave behind the auditing tendencies which drove me to measure responses against guidelines; I needed to go deeper and explore the whys and wherefores. To do this, I had to face up to the fact that I was transitioning from clinician colleague to colleague AND researcher, thereby beginning on the path from insider to something else. If I was honest with myself, maybe I had thought that this would just be a chat with colleagues, nothing too strenuous. I was starting to appreciate that to make this research meaningful I couldn’t just be an insider.

Another early challenge was recognising that qualitative research can be looked down on in circles where quantitative approaches have traditionally held sway. Greenhalgh and colleagues’ (Greenhalgh et al., 2016) well-publicised open letter to the British Medical Journal and the journal’s response hints as the uphill road qualitative researchers may still anticipate when seeking to be respected in ‘conventional’ medical research circles. When comparing PhD notes with another colleague who was doing a basic science research project, he offhandedly commented, “Wow, so you can get a PhD just doing that…talking to people…It sounds…great…” I was left in no doubt that he perceived the rigor of my PhD to be less than his. As mentioned, medics are famously competitive. I bridled, joked, changed the subject and stored up the exchange to ruminate on. It has been one of many similar. What does this mean for my research? On the good days, it is a call to arms to do excellent research which is informed by theory, meticulously described and critically analysed. On bad days, I feel like an imposter in many senses. Is this enough for a PhD? Am I medic enough for the medics and ‘qual’ enough for the qualitative researchers? There is no solution for this and, on the whole, I think that having to defend my approach is leading to stronger work. Maybe it is one of the reasons I am writing this account.

These notes illustrate my first steps away from complete ‘insider’. The nebulous meaning of the term ‘insider’ has been discussed at length elsewhere (Chavez, 2008). Commentators have variously considered the insider position to fall along a spectrum of how truly one is an insider (Banks, 1998) or argued that the insider position is ‘ever-shifting and permeable’ (Naples, 1996); positionality for the insider with multiple roles which are neither binary nor permanent has been termed ‘liquid inbetweener’ (Barnes, 2021). I am not sure it is helpful to propose another iteration for the insider outsider debate, apart from to remark that my personal experience was to find myself becoming, irreversibly, neither true insider nor true outsider. As a critical researcher, I was no longer a pure insider, but I neither could nor wanted to let go entirely my hard-won clinical identity. For the purposes of this article I have used the term insider but with the caveat that I did not consider this position complete or fixed.

Recruitment

The ethics approvals went through promptly and we were ready to recruit. The recruitment strategy allowed members of our research team to contact colleagues as well as disseminating the advertisement across the NHS healthcare Trust, ultimately working towards purposive sampling according to specialty and grade. We chose to recruit within the healthcare Trust with which my team and I have longstanding associations, anticipating access to physicians (although the Trust comprises several hospitals so I would not have existing relationships with all participants) and baseline understanding of local processes. Physicians usually practice in multiple centres as part of their training, and there are national guidelines about TEP, so the participants were likely to bring views reflecting a broad professional experience.

I have a vivid memory of entering the hospital I knew so well, wearing a different identity ‘hat’. The familiar thrill of adrenaline as I entered the foyer usually heralded a stress-filled clinical shift but this time reflected the new challenge of finding physicians to participate in my study. I wandered around the hospital visiting areas I knew would be frequented by potential participants. It felt strange. I am used to being useful, wanted, greeted with relief by a frightened junior with a sick patient on their hands or a warm welcome from a senior to discuss the latest ward conundrums which I would be integral in helping solve. Now I was visible in a different way, an inconvenience. Winter pressures were starting to build and I felt guilty that I was not part of the all-hands-on-deck effort. I left with a moderate list of potential participants to email and a solidifying feeling that something had changed: I had still considered myself physician first and foremost, but, no longer on the rota, I wasn’t part of the gang anymore. This probably happened on the day of my last shift but it only felt real when I went back in a new guise. There was nothing wrong, physicians step out to do research all the time and it is considered advantageous. But I suddenly felt in limbo, and that is rarely comfortable. In the end, about half of the participants were physicians I knew well professionally and the other half volunteered through local advertising after a rota coordinator with whom I had many interactions over the years kindly agreed to send round the email. Some people I knew well didn’t respond to my in-person request (and yes, I did feel a little betrayed), while others I had never met must just have read the advertisement and, I assume, thought the topic looked important.

Looking back, I have tried to make sense of how being an insider during recruitment influenced the study. At a practical level, I would have struggled to access most participants without my clinical credentials and those of my research team. Familiarity with colleagues is also likely to have encouraged some to ‘help’ me with my research, although it is possible that potential participants declined to be involved for the same reason. Did my insider position create a sample of participants with common attitudes? I probably did approach people I thought might be more receptive, but while there may be a volunteer bias in terms of the ‘type of person’ willing to participate in any research, I am not convinced that those who responded to me as an insider shared particular characteristics. In terms of recruitment ‘success’ in accessing participants and being able to sample purposively by specialty and seniority, being an insider was an undoubted advantage.

It is worth noting that potential participants will likely consciously or otherwise have considered the intersectionality of my interrelating social labels (Collins, 2015) beyond my insider position, including race, class, gender, sexuality, nation, ethnicity, ability, age, religion (Collins et al., 2021): while I could strategically deploy my ‘ethnographic toolkit’ (Reyes, 2018) of physician and colleague to some advantage, there will be other facets of my identity influencing interactions with potential participants. I am a white-British female in my early 30s. The role of women in medicine is appropriately subject to ongoing discussion. In 2022, 49% licensed doctors in the UK were female (General Medical Council, 2023b), but high rates of sexism are still reported (British Medical Association, 2021) and there remain concerns that women are under-represented in senior academic or medico-political roles (Medical Womens Federation, 2024). Whilst I certainly have been mindful of my gender in other encounters during my career, I did not feel it negatively influenced the experiences described in this study. This may be explained in part by the high visibility of women in leadership positions in my workplace. I also did not feel that my ethnicity was a factor, although maybe that reflects my ‘white privilege’ (McIntosh, 1989). The city in which I work has a relatively diverse workforce, including its clinical staff (NHS England, 2020), albeit there are ongoing efforts to improve equality. Perhaps what I am describing is an advantaged position where I was well-received and therefore less sensitive to perceived biases. While I considered my insider status to be the most significant aspect of my positionality, it is possible that other physician researchers might have a different experience from me.

It is also important to remember that there are numerous reasons specific to the potential participant why they may agree to participate in a (qualitative) study (Di Marco & Sandberg, 2023): their views on the value of the research, and maybe even on whether qualitative research was worth their time; personal confidence that their views on an ethically and legally intricate topic would stand the test of an interview; clinical pressures as winter hit, professional pressures in specialty recruitment season. My insider perspective helps me to understand but not alter these influences.

The most challenging consequence of my recruitment experience was, I believe, my reaction and how this affected my confidence moving on to the next stages of the study. I was using my insider position to gain access to a community uniquely well-positioned to help explore my research topic, which was academically a sound step. Stepping out of a full time clinical role is recognised to involve guilt and loss of identity (Jamal, 2023) and I found approaching colleagues as a researcher made me question my sense of self. I had a growing awareness that I was no longer doing this research entirely ‘from the inside’, but I did not know what to do with this realisation. The interactions described earlier with colleagues during the planning stage had initially challenged my identity but soon felt constructive, helping me form a research question which better appreciated the complexity of the topic. That transition in thinking occurred in my own head and on paper, but physically attempting recruitment was testing my insider identity on all too real a stage. Perhaps I had to get lost before I could find myself an identity comfortable as both physician and researcher.

Data Collection

Setting up the interviews involved agreeing a mutually convenient date and gaining consent. It sounds straightforward, but again my insider position affected how things proceeded. Hierarchy is often important in the workplace and in medicine particularly so (Vanstone & Grierson, 2022). I am a junior registrar; the participants would mostly have known my ‘grade’, and I similarly was broadly aware of their level of seniority. This mutual awareness of relative authority in our clinical backgrounds would have been less significant for an outsider researcher. A consultant colleague asked me to email her a reminder (for an interview via video conferencing, clearly displayed in an electronic calendar) the week before. Nothing wrong with that per se, but it felt like she was asserting her authority, subliminally saying, ‘my time is more important than yours, it is your responsibility if this doesn’t happen’. It worked both ways, though: when physicians at roughly the same stage as me were slow sending back their consent I felt hesitant nagging these colleague-friends. All little things, but they subtly set the tone for the interview where our relationship was more than just researcher and researched.

Some of the interviews were in person, the majority via video conferencing. My first few interviews were on-site at the hospital with consultants in their offices. Interviewing ‘elites’ can bring challenges around setting up the interview, such as scheduling pressures or a heightened consciousness from the interviewer with inferior status to present themselves well (Mikecz, 2012; Ruan, 2020). Junior doctors usually find themselves in a consultant’s office for formal and moderately high-stakes meetings. Climbing up the stairs my heart beat a little faster than normal as I subconsciously prepared for an end of placement ‘sign-off’, a conversation about a ‘difficult case’, or an opportunity to discuss a career-advancing project. On arrival I did the customary dance about which chair I might use in the shared office, ever mindful of an embarrassing encounter where I chose the Wrong One as a medical student. They were all kind, polite, busy; an eye on the never-ending emails flashing up on screen in case one was another fire to fight and an ear out to their mobile phone going off (never declined, usually a muttered “sorry, do you mind if I answer this?” as the call was taken). Perhaps it was because of these feelings, barely acknowledged at the time, that I transitioned to video conferencing for later interviews. As we were all accustomed to the format, I found they worked well and the conversations through our screen windows seemed to proceed just as openly as those in person. It was not all plain-sailing. WiFi glitches were met frostily by a consultant I had been keen to interview, the fragile dynamic disintegrating as surely as the audio on my Dictaphone. With junior colleagues I felt strangely more ready to let them into my life in the rapid back and forth of electronic messages to set up the meeting, revealing I was running late after sleeping in following a busy shift the day before, or needed to rearrange due to a funeral. All professionally expert in small talk, sympathy, work chat, and used to a working dynamic that involves long hours where life and work can roll into one, our interviews opened with a follow on from these exchanges before switching into formal mode once I set the dictaphone running. Some of these experiences are surely commonplace in qualitative interviews, albeit not always documented, due to their essentially human nature. For an insider researcher, the formality of the interview tests how much one has, can or wants to leave one’s old world behind. As a physician, there were elements of hierarchy and collegiality which found their way into the peri-interview dynamic and reminded both the participants and me that I am one of them, setting the scene for the conversation itself…

The interviews were fascinating. There was a line I used several times when asking people to participate, and it was true: “I find all this (Treatment escalation planning conversations) really difficult and I would really enjoy being able just to pick your brains on what you do”. There was a huge advantage in speaking the same clinical language. The clinical scenario and use of imaginary case studies as a starting point for discussion seemed familiar and natural. My participants and I rattled on quite merrily discussing the intricacies of clinical scenarios and decision making. They could describe their thinking without stopping to explain, and I could join in. It felt good, mostly because the interviews simply flowed and partly because I felt a satisfaction knowing that it was me being a physician insider that made this possible. Working in the same organisation also meant that knowledge of the local computer systems and pathways could be assumed. This demonstration of ‘studying sideways’ has been previously remarked, as an alternative to ‘studying up’ or ‘studying down’ a social hierarchy (Plesner, 2011). The following response, from an intensive care specialist, was given to my question about outcomes to consider when deciding whether ventilation and CPR would be appropriate. The participant describes a series of scenarios and possible sequelae, using reasoning based on physiology familiar to us both.

I think, if he were to arrest, his heart is already poorly with ischaemic heart disease. It’s going to be really hard to resuscitate or get ROSC back. He’s got a history of atrial fibrillation, even though he’s on direct oral anticoagulant, he might still have clots that might give him cause him strokes. Or it could go the other way, he might end up bleeding because he’s on oral anticoagulant. If he did not arrest and he just deteriorates from respiratory point of view, he’s got a background of asthma, he’s an ex-smoker. He would probably have a baseline, loss in his respiratory reserve. And it’s never a single organ failure when the heart or the lungs are involved, they bring the other organ along with them. If end up tubing him first, then I would not manage to extubate him because his dependence on the ventilation would be quite significant. And once he is on positive pressure ventilation that again can cause a heart problem. It can cause varied pressure changes and stuff. Overall, I think if he were to deteriorate he could end up with multi-organ failure.

As well as sharing a clinical language, participants also seemed to recognise a shared experience. They talked about clinical pressures, difficult communication experiences and litigation fears as if I could feel their strain. We shared flashes of light from a gallows humour exchange and moments of shade recalling harsh memories of working during Covid-19. Researching topics which are close to home can result in a ‘deadening effect’ where participants assume common understanding with the interviewer and therefore do not explain their meaning. A technique for handling this is ‘making the familiar strange’ (Mannay, 2010), wherein I needed to check myself and encourage the physicians to expand on their answers. This proved important in several instances where depth of understanding might have been lost if they and I had accepted what initially passed for unquestionable ‘facts’, such as ‘paternalism is bad’. Talking about views on training for TEP conversations, a registrar colleague said,

I don’t know how you feel, but I feel like…

The commonality did at times prove a double-edged sword. Any ‘positional piety’ (Cousin, 2010) I might have been feeling, smug that my insider position gave me unquestioned superiority, was countered by challenges. I have been so immersed in clinical life that yes I am fully aware of the ‘status quo’, but this made me all the more aware when I edged towards questioning it. Opening a discussion about ‘What is TEP?’, a consultant used the following words, which to me implied distinction between an acceptable and unacceptable definition:

Treatment escalation to me, I would hope to others, would mean…

An important aspect of TEP decisions is balancing potential harms of intervention with anticipated gain. It is not possible to predict with complete certainty what an outcome will be, therefore judgement calls must be made. I have developed a clinical approach and I know what many other physicians in my clinical environment are likely to think an ‘appropriate’ course of action, but I saw part of my role as a researcher to test extremes of situations, such as delivering cardiopulmonary resuscitation to a patient who is very unlikely to survive. This appeared uncomfortable to participants. Instead of the colleague who, like them, makes ‘sensible’ decisions, I risked acquiring a reputation of being less reliable. Talking about how to decide treatment thresholds according to a patient’s baseline, an emergency medicine doctor said,

I realise this, as you do, I know because I’ve worked with you, that there’s no point in flogging a dead horse.

Awareness of colleagues’ anticipated beliefs around ethical decision-making tested my resolve, as I retained my ‘insider’ wish to be respected and approved of, especially by seniors with whom I may have to work in future. This challenge of interviewing peers has been remarked previously, with the associated desire for it not to be ‘a socially unpleasant occasion’ (Platt, 1981). Looking back, these ‘difficult questions’, challenging accepted attitudes, were one of the most useful lines of questioning as they helped move my thinking from the uncritical descriptive approach described in the early stages of my planning to one more analytical. This benefit of confrontation has been described in the context of ‘studying sideways’ (Plesner, 2011).

The role of hierarchy proved interesting during the interview exchange. In my researcher role, I pushed points with senior physicians in a way I would not consider as their junior colleague. All were pleasant but I had a feeling of firmly but kindly being put in my place. It was sometimes implied that if I had the experience they did I would understand, and as I did not I shouldn’t keep pressing. I was an insider running the risk of being ostracised. On reflection, insider awareness of my relatively junior position may also have made me more sensitive to comments I perceived as a nudge back into line but were actually made with less weighted intent. Describing a thought process when predicting patient outcomes following treatment escalation, physicians said,

We know that statistically, don’t we, in hospital, out of hospital. There are loads of papers that have been written on outcomes and survivals and stuff, so I think we can do that.

Actually, when you’ve seen enough people at that point, it’s quite obvious to predict.

Often, there are concerns about the socially more powerful researcher exerting control over vulnerable participants; in my case, I felt disempowered as the participants wittingly or unwittingly demonstrated their superiority (Sterie et al., 2023). However, looking back there may even have been times where I used this power discrepancy to advantage to encourage seniors to ‘teach’ me their position – was this colluding with an unequal positioning (Gewirtz & Ozga, 1994) or simply turning the inevitable to my advantage? Where we strayed into controversial areas such as the role of resources on decision-making, I occasionally had the feeling I was being given a politically correct answer, but of course I have no evidence to prove this. It has been remarked that the power gradient between interviewer and interviewee in elite interviews can influence responses and that elite interviewees can be adept at giving the ‘public relations’ version of events (Mikecz, 2012). That said, I mostly found that the physicians gave direct answers to my questions.

Writing Up

I have found the analysis really challenging, and am often reminded of the ‘wrestling a sea monster’ analogy cited in Braun and Clarke’s Reflexive Thematic Analysis guide (Braun & Clarke, 2022). This in part presumably stems from my relative inexperience and from a natural desire to do my data justice. However, my positionality continues to shape my thinking. In trying to make sense of the ideas and generate meaningful themes, I have found myself reflecting on, ‘What do I (as a physician) think about the topic?’. This has proven constructive in gathering my thoughts but I have needed to remind myself that this is first and foremost a synthesis of others’ perspectives. My write-up seeks to convey honestly what I believe to be the shared meaning running through the interviews, but I accept that this is my interpretation (Sandelowski, 2004) and influenced by my insider position.

I have also felt a responsibility to the colleagues whom I respect and who gave their time to support my research. This is typical of the insider challenge of a sense of duty to existing relationships, or a tendency towards a ‘rose-colored observational lens’ filtering out only the good (Chavez, 2008). I am mindful of how my report will be received by the medical community. This research is designed neither to ‘out’ colleagues nor to endorse them unquestioningly. My early inkling that it could not just be an audit against guidelines feels important, and I have tried to remain true to my goal of seeking to generate deep understanding from a position of open-minded questioning about how physicians view shared decision-making in treatment escalation planning. The participants spoke to me with a frankness I doubt would be achieved with a non-clinical interviewer and the honesty was sometimes disconcerting. I interpreted the conversations through the lens of my insider position, while an outsider might react differently. I have chosen quotations to illustrate themes which I felt usefully conveyed meaning rather than simply stood out as a striking turn of phrase; while I do not feel that I am censoring the data, I am aware that an outsider might choose their illustrative quotations differently.

Reflection

I have found this reflexive process educational, cathartic even, but not without anxiety. Reflection is encouraged, even mandated, as a healthcare professional. The General Medical Council, which regulates doctors in the UK, states that reflection is vital to personal wellbeing as well as patient care (General Medical Council, 2023a). Reflection is considered a constructive process to promote learning from good and bad experiences (Kolb & Plovnick, 1974). I have mostly enjoyed ‘reflecting’; it is perhaps not a coincidence that I am doing a qualitative methods PhD. However, reflective practice has historically not been without drawbacks which have perhaps contributed to my unease. For doctors in training, a requirement ‘To reflect’ in order to progress results in many approaching it as yet another tick-box task to complete. In all honesty, when I started out doing qualitative research I kept a – bare-bones – reflexive journal because I had been told I should. It has only been with experience that I have appreciated the relevance of my positionality to my research. The role of reflective practice (implicated and widely discussed even if not used directly in Court) in the famous and distressing Bawa-Garba case, where the paediatrician was removed from the medical register and given a suspended sentence, continues to resonate with doctors (Nicholl, 2018) and currently reflective notes can be required by a court (General Medical Council, 2023a). These considerations are not directly relevant to this article but they are likely to influence how doctors feel about reflexivity. In my more immediate research context, I am conscious that I am writing about my experience as an insider interacting with colleagues whom I respect and with whom I may have to work in future. I wish to be open about my reactions but how will this be received?

Entering the world of qualitative research is a joy but the transition has not always been easy. I moved from working in a clinical field where I felt reasonably comfortable to joining a research environment where I am very much the junior. Finding the confidence to seek training and advice can take time. I have also been aware of how I might be received as a physician in the established academic community. I feel conscious of the need to balance employing my clinical experience usefully for the research with humility, recognising that clinical experience does not equal academic expertise. In writing this article, I could be criticised for portraying my experience as ‘more important’ simply because I am a physician, although I hope that my critical account will be received more generously.

Advice to Other (Physician) Insider Researchers

I anticipate that this reflexive piece may offer a naturalistic generalisability (Stake, 1978) which resonates with other physician researchers and prompts constructive reflection on their own experiences. I am also hopeful that there will be some transferability (Tracy, 2010) to other healthcare professionals undertaking qualitative research amongst colleagues, and to insider researchers more generally.

In this article, I draw on a rich history of discussion around the insider position which I have detailed throughout the text. Several of the themes encountered here, such as loyalty to one’s community (Chavez, 2008) and hierarchy (Mikecz, 2012), have been considered extensively in the literature. Here, I present a critical, nuanced perspective examining how these ideas relate to a physician researcher studying colleagues in a clinical hospital environment. I extend the discussion by describing how feeling uncomfortable as an insider physician researcher ultimately added depth to the research question and the output of clinically-meaningful themes, as well as contributing to considered self-awareness about professional identity.

I write this piece from a perspective of optimism. I commenced this part of my research journey research hopeful, even presuming, that my clinical role would confer advantage. On the way I struggled with unanticipated challenges incumbent upon being an insider. Emerging from the study and engaging in critical reflection, I view my overall experience positively. The following table summarises my assessment of the advantages and challenges of being an insider physician researcher. My notes are designed to be encouraging to others, acknowledging difficulties in order to validate those experiencing similar and suggesting a rationalisation and mindset which may helpful in moving forwards. Some apply specifically to physicians, some to clinicians in general and others to insider researchers from any sphere.

	Advantages	Challenges
Planning	Clinician researchers may be able to use their experiences, for example interactions with patients or colleagues, or experiences of working in health systems, to formulate clinically-relevant research questions.	Peer critique of qualitative research, where quantitative approaches have traditionally been more accepted by colleagues, can be unnerving. This may particularly affect more junior researchers or clinicians.
	Critical reflection prompted by the challenge of transitioning between insider clinician and outsider researcher roles can add depth to the research question, such as moving beyond simplistic descriptions to more open-minded exploration of why a phenomenon may occur.	Transitioning between professional roles can be unsettling. This is widely relevant, but especially so when one has a highly immersive professional identity, as is the case for many physicians. In the planning stage of research, starting to conceptualise and discuss study ideas which question professional norms can lead to uncertainty about one’s clinical/academic identity.
	The early critique of my ideas ultimately proved useful in strengthening the research question to be more rigorous and clinically relevant. It is better to respond to these challenges early and thereby produce research which will be more meaningful to stakeholders, even if this is initially uncomfortable.
Recruitment	The clinical ‘world’ may be difficult to access for outsiders, so the insider position can be beneficial in recruiting physician participants.	Encountering colleagues when seeking to recruit can highlight one’s transition between insider and researcher, leading to further questioning of one’s clinical/academic identity
	Knowledge of subject-specific professional roles and hierarchies can be useful in developing a purposive sampling strategy, for example according to clinical specialties and seniorities, to gather perspectives relevant to the research question.	It is important to be mindful that pre-existing relationships may give insight into participants’ viewpoints. This is not necessarily problematic, but needs to be acknowledged and reflected on, for example so that there is not inadvertent selection towards those favouring one’s own opinions.
	Understanding potential participant considerations about recruitment to the study is important in considering if and how these can be addressed, in order to maximise recruitment or best capture representation from a varied cohort.
	Finding one’s professional identify is likely to be a lifelong struggle. Encounters and reflection leading to a more nuanced, broader perspective can only be valuable for any and all of one’s identity ‘hats’.
Data collection	Shared clinical language can facilitate in-depth conversation. The insider position may be particularly advantageous where there are technical terms or complex specialised concepts which could be unfamiliar to outsiders.	Awareness of professional hierarchies, prevalent in medicine, may influence dynamics between the researcher and participant.
	Sympathy to the clinical context means that an insider can be aware of and sensitive to challenging issues. They can also develop rapport through demonstration of shared experience.	Physician researchers are likely to be mindful of their professional reputation and may find it difficult to challenge the status quo of accepted clinical practice with colleagues.
		While shared clinical language can facilitate discussion, it is important to be mindful not to make assumptions of implied meaning. Actively clarifying participant responses invites sense-making which may be different from what the insider interviewer has assumed, gives participants space to venture unconventional opinions and enhances understanding of viewpoints.
	Don’t be afraid to ask ‘why’, ‘why’, and ‘why’ again. Familiarity with the professional context is a strong starting point for these difficult questions, and challenging assumptions drives deeper understanding which can be important academically and in one’s own clinical practice.
Analysis	An insider awareness of clinical culture can prompt development of themes which are clinically-meaningful to physician colleagues and in some cases may be more immediately relatable to recommendations for practice.	Awareness of colleagues’ scrutiny could cause an insider researcher to present results in a way they anticipate will be acceptable. This may particularly be the case in medicine where there is a strong sense of professional identify and community.
		It is important to be aware of disproportionately inputting one’s own clinical perspective into the analysis. This may occur through subconsciously connecting more strongly with personally-resonant themes during the analysis, drawing on one’s own experience to make sense of themes or using the research as a stage to advance one’s own opinions without being transparent about how these fit within the data.
	Debriefing with supervisors and group reflexivity can be valuable in generating analytic outputs which are strengthened by awareness of positionality.

Conclusion

In this paper I have critically explored my experience of being an ‘insider’ researcher. As a physician undertaking qualitative research with a clinical focus, I was able to use my clinical role to help me define a clinically-relevant research question, access physician participants for recruitment and facilitate an in-depth interview around a complex topic. My outsider perspective as a physician-turned qualitative PhD researcher, especially one planning to continue clinical responsibilities, influenced the dynamics of planning, negotiating and analysing the interviews and challenged my own sense of identity. Through this research experience, I have become more comfortable with no longer being either truly insider or outsider and recognise that challenges of the transition ultimately strengthened my research. Given a paucity of physicians engaging with qualitative research, I hope that my experience and critical account will be beneficial to others embarking on a similar journey as well as to those interested in insider research.

Footnotes

Acknowledgments

I would like to acknowledge my PhD supervisors: Prof. Stephen J. Brett, Prof. Mary Wells, Prof. Cecilia Vindrola-Padros.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: BW is supported by an unrestricted educational grant from HCA international and The open access fee was paid from the Imperial College London Open Access Fund. Infrastructure support for the research was provided by the NIHR Imperial Biomedical Research Centre. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Ethical Statement

ORCID iD

Bronwen Elizabeth Warner

Data Availability Statement

Anonymised interview data is available on direct application to the author.

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