The inner portrait: What does reflexivity in qualitative health professions education research look like?

INTRODUCTION

Seeing comes before words. The child looks and recognizes before it can speak. But there is also another sense in which seeing comes before words. It is seeing which establishes our place in the surrounding world; we explain that world with words, but words can never undo the fact that we are surrounded by it. The relation between what we see and what we know is never settled. John Berger, Ways of Seeing, 1972

The quote above from John Berger's “Ways of Seeing”, ¹ encapsulates how we, the authors, view elements of reflexivity in qualitative research. Qualitative research is subjective as it relies on personal interpretations and human experiences to understand complex human behaviors and social phenomena. It is also contextual, as Dodgson states “it occurs within a specific time and place between two or more people”. ^{2 (p220)} Looking through this lens, “how we come to know that world is constructed through social interaction”, ^{3 (p846)} as meanings are actively co‐constructed throughout the research process. ⁴ So, for others to understand the meanings behind the phenomena you are exploring, we (the researchers) must reveal what the research space looks like, both externally and internally. We, as researchers, need to—essentially—generate a descriptive picture of the view and vantage point we are taking when exploring the topic. This includes our personal perspectives, feelings, opinions and interpretations that vary from one individual to another as they are influenced by an individual's unique thoughts, emotions and sociocultural background. Describing the external research space, or the natural context in which the qualitative research takes place is relatively straight forward, however, revealing the internal space and how subjectivity shapes you as a researcher is more complex and counters how many of us are taught to think about research, particularly those of us from the scientific or positivist research paradigm—which include many anatomy and health professions education researchers.

The transparent process of describing your internal space, including deepening understandings that emerge through social interactions with research participants, has been described as a reflexive “wakefulness” ⁵ with many scholars agreeing that it is one of the most important and challenging parts of doing qualitative work. ⁶ , ⁷ , ⁸ , ⁹ This viewpoint article will explore an arts‐based approach for digging deeper into the internal researcher space, providing guidance on a more rigorous and reflexive approach to qualitative research. As an interdisciplinary team, we harnessed the multidisciplinary edge effect ⁴ by drawing on diverse worldviews, including first author GB, a health professions educator, nurse, and narrative researcher; SW, a medical and fine art portrait photographer; and MDL, a well‐known anatomist, to shed some light on what personal and interpersonal reflexivity in health professions education research (HPER) looks like.

Acknowledging Berger's ¹ quote above—if what we see and what we know is never settled, and reflexivity involves the conscious act of self‐ knowing (which is always evolving), we endeavor to present an approach based on our own experiences of reflexivity through the arts‐based practice lens of narrative portraiture. We will first briefly describe what reflexivity is and why it is important in HPER. We then present author MDL's narrative that honors the richness of her internal space as she shares her written personal reflexive statement of being a woman, educator, and qualitative researcher in an anatomist's world. Then, we share experiential insights on our (all authors) experiences of interpersonal reflexivity as we draw on MDL's written reflexive statement to co‐create a narrative portrait. A narrative portrait is a photograph infused with narrative artifacts to make the invisible parts of the researcher's internal space—even to MDL—self‐visible. In many ways, co‐creating MDL's narrative portrait mirrors the dialogic relationships between researcher and participant in qualitative HPER work, providing an applied case example of what interpersonal reflexivity looks like and illustrating its power in eliciting the more challenging aspects of personal reflexivity. Through this lens, we hope to shed some light on how this process can help other qualitative HPE researchers explore their own inner portrait.

WHAT IS REFLEXIVITY AND WHY IS IT IMPORTANT IN HPER?

In the mid‐20th century, as qualitative research gained prominence, scholars began to recognize the importance and impact of the researcher's role and perspective on influencing each stage of the research process. Despite this historical recognition, HPE scholars have remained largely impervious to embracing the multi‐dimensional nature of reflexive practice in HPER. So, as qualitative HPERs, we were delighted by the release of AMEE's guide to reflexivity in qualitative research, ¹⁰ particularly in its framing of “reflexivity as a way to embrace and value researchers' subjectivity”.^(p241) Finally, we did not feel so alone engaging in humanistic and qualitative education research approaches that aims to: counteract a biomedical view of the body, ¹¹ raise awareness and reduce dehumanizing language used in healthcare practice, education and research ¹² and challenge the hierarchical healthcare relationship through partnering with healthcare consumers to co‐design HPE. ¹³

Before we move to defining what reflexivity is, it is important to differentiate a related term. A researcher's positionality includes explicitly outlining researcher's background and social identities (e.g. race, gender, cultural experiences, beliefs and values) that may influence their perspective of the research, including stating assumptions or potential biases related to what is being studied, the research context, design, and processes. ¹⁴ Whereas reflexivity involves a deeper, ongoing reflective process towards self‐understanding through questioning (often unexplored) assumptions and/or biases that cut across our personal and professional belief and value systems, which include acknowledging how they influence the researcher's engagement with the research process. This includes the evolution of thoughts, feelings, and experiences during research interactions that influence the study and shape the findings. Please see Olmos‐Vega et al., ¹⁰ for some illustrative examples on reflexivity statements and structured team‐reflexive discussions in qualitative HPER work.

Reflexivity can be defined as:

turning of the researcher lens back onto oneself to recognise and take responsibility for one's own situatedness within the research and the effect that it may have on the setting and people being studied, questions being asked, data being collected and its interpretation. ^{15 (p220)}

It is important to note that according to Walsh as cited in Olmos‐Vega et al. ¹⁰ there are four interconnected dimensions of reflexive processes: personal, interpersonal, methodological, and contextual. In this paper, we focus on the personal and interpersonal dimensions as they relate to the self‐discovery process of the internal researcher space through the arts‐based practice of narrative portraiture (To learn more about the methodological and contextual reflexive process in HPER see: Olmos‐Vega et al. ¹⁰ ).

So, why is reflexivity important? First, it is now widely accepted as part of doing qualitive research, with many scholars asserting reflexivity as the gold standard for responsible positioning of themselves in their writings, ^{16 (p229)} determining trustworthiness, including quality, rigor and credibility. ¹⁷ Second, heightening your reflexive awareness deepens interpretations of the data. For example, the act of engaging in dialogic conversation and social interaction with research participants creates a space whereby narratives and interpretations are exchanged, recounted and reconstructed reciprocally. ⁶ This fusion between two narrative perspectives (researcher and participant) converges into one narrative, a concept referred to as the “third voice”. ⁶ From our experience, this third voice is more nuanced and produces richer contextualized findings enhancing the relevance of the research. Third, reflexivity fosters socially responsible and ethical research practice, especially in examining unconscious/implicit bias and hidden power dynamics that reinforce health professions education system inequities. ¹⁸ Fourth and finally, reflexivity facilitates methodological transparency, including being open, flexible and responsive to the natural context being accountable for evolving decisions that “are ethical, rigorous and paradigmatically aligned”. ^{10 (p245)}

A CASE EXAMPLE

If you want to know me, then you must know my story, for my story defines who I am. And if I want to know myself, to gain insight into the meaning of my own life, then I, too, must come to know my own story. ^{19 (p11)}

The ancient aphorism “know thyself” originally inscribed upon the Temple of Apollo in Greece, speaks to the importance of introspection, self‐awareness, and knowing to understand ourselves, our own limits, and internal motivations. This saying has transcended time, influencing philosophical thought across disciplines, including Socrates, who believed that true wisdom lies in our ability to not only “know thyself” but also obtain knowledge of the self—referred to as to “see thyself”. Here, MDL shares her written personal reflexive statement below as she constructs her narrative identity through life stories ¹⁹ she shares—curiously asking existential questions like: Who am I? Am I more than the roles I play in my life? What and who has shaped my personal and professional journey? What fuels my desire to engage in qualitative work in a predominantly biomedical positivist discipline (anatomy)?

MICHELLE'S REFLEXIVE STATEMENT

When I was growing up, my dad's nightly question to me as he tucked me in was: “What are you going to be when you grow up?” It didn't matter what my answer was—as long as I had one. From what I recall, my responses were all very science based. I wanted to be an ophthalmologist (quite specific given my age) or a scientist. As far back as I can remember—the person I wanted to be was centred around my seemingly unquenchable curiosity.

By the time I went to University, my curiosity coupled with my passion to understand the world around me distilled down to two possible career avenues: scientist or medical doctor. I hated memorisation. The reputation of medical school—particularly of anatomy—was that these courses required rote memorisation of every single page of Gray's anatomy—so I enthusiastically pursued bench science. I graduated, with honors, with a Bachelor of Arts (BA) in Biology. In the US, a BA was common even for those majoring in the sciences. What this meant is that I took all the same biology, chemistry and science courses of those getting a BS in Biology—as well as courses in the Arts and Philosophy. While such degrees might seem odd in my new home in Australia, this blending of “Arts” and “Science” helped shaped my perspective of the world. This unique blending has helped me see how one exists only enmeshed with the other. To quote my recent article ²⁰ : “In my science courses, I learned facts and figures. In my humanities courses, I learned how these truths are situated in the natural world.” It is this enmeshed and intertwined view of the arts with the sciences that has shaped my approach to education research into the present day.

I credit this blended experience to laying the foundation necessary for my transition from positivist to interpretivist worldview. As I transitioned between these worldviews, I came to understand that my experiences, perspectives, and knowledges were all influencing the way I understood the world—and thus influenced the research and teaching I undertook as well as my perception of these experiences.

However, my professional journey did not come without challenges. My journey from scientist by training to interpretivist by choice was both hard and transformative. I felt lost at the beginning, and out of my depth. I saw my background in science—one built from a PhD where I studied cell biology to a post‐doc where I studied nuclear pore formation—as an impediment to my progress in qualitative methods and HPER. I had the all‐to‐common view that education research, particularly qualitative research, was fluffy and not ‘scientific’—which I (at the time) thought was the only true and real research! I soon realized these assumed ‘fluffy’ qualitative methods were critically important in answering questions that I began asking—and that by not engaging with these methods I was prohibiting myself from learning more.

So there I stood at a threshold between the positivist world I knew and the interpretivist world I was just beginning to acknowledge—and felt filled with uncertainty. People experienced in education research were using words I couldn't understand (e.g. epistemology, ontology, constructivism and so on) and using methods unfamiliar to me. What kept me going was my innate curiosity and lifelong desire to understand the world around me—and a recognition that my current toolkit and skillset were only getting me so far.

What also kept me going was the challenge. Like so many anatomy educators before me, as I moved in anatomy leadership positions—I was finding myself more frequently in the position of being challenged about the cost versus benefit of anatomy education. From the outside, the anatomy learning environment appears to cost heaps of money and time. When either of these limited resources is under scrutiny—the microscope (pun intended) tends to be squarely on Anatomy. In such circumstances, I would find myself defending the anatomy discipline with passion—but at the time without much evidence.

Administrators would say things like “…but medical students also need to learn [fill in the blank]”—with the blank being filled with topics such as clinical skills, clinical reasoning, healthcare systems science, medical ethics—and so on. They would continue “so we need to cut anatomy time to allow for teaching time devoted to these [other areas]”.

I would leave these meetings feeling frustrated. My experiences, observations, and perspectives suggested that these “other” skills the administrators were referring to were being developed through anatomy education. I began to wonder if we could better signpost the breadth of learning within anatomy education and how it fostered workplace‐ready skills. To do this, though, I needed to better understand what learners were experiencing in the anatomy learning environment, and I soon found myself realizing that a survey or quantitative data collection wouldn't be fit‐for‐purpose. I needed to understand the context and unique experiences of those engaged with anatomy learning and capture the nuance and complexity of this learning environment.

This marked my slow but committed journey into the world of qualitative research. In fact, a ‘memory’ just appeared in my feed where I posted “It's official! Just got my first paper about anatomy education research accepted! Yay” from March, 2012. I can still remember the feeling of pride and joy that I had somehow made a little progress in this journey. I continued to be inspired to progress in this journey both by my personal learning background and the challenges I faced with developing effective clinical anatomy education. While at the beginning of this transition from positivist to interpretivist I thought of myself as an imposter (that feeling was strong in 2012!), I now recognize my power in being a translator between these two research worldviews.

Reflexivity doesn't come naturally to me. My educational training focused on maintaining objectivity and removing personal values when considering research. My socio‐cultural upbringing also prioritized objectivity over subjectivity inherent in reflective processes. I recognize, however, just how critical reflexivity is to HPER. Without transparency of what view I am taking, and why I am taking it, the understanding of the why, how, and what related to my research is impossible to identify.

PROFESSOR CURIOSITATIS: A NARRATIVE PORTRAIT

Drawing on McAdams ¹⁹ work on how our quest for identity is played out in the social contexts of our lives, here we add another layer to MDL's personal reflexive statement to describe how we embarked on co‐creating narrative portraiture which at its core centres on interpersonal reflexivity as we demonstrate how our multidisciplinary collaboration deepened MDL reflexive self‐knowing towards a new way of seeing and understanding self. Early in 2023, GB emailed MDL to invite her to bravely step in front of SW's lens to capture a narrative portrait of her internal space. Based on Depth of Field (DOF), an innovative health humanities research methodology (co‐founded by authors GB & SW) narrative portraits draw on voice (narrative) and art (narrative artifacts and visual methodologies) to deepen our understandings of self (See Figure 1).

FIGURE 1.

Professor Curiositatis.

In the spirit of being a super organized educator, MDL arrives at the first meeting with SW with a power point presentation—communicating to SW her personal narrative. Up until this time, MDLs has adopted a constructivist lens (with a “v”) through an individual construction process. ³ Over the next few months, MDL and SW meet for a series of in‐depth conversations that go beyond personal reflexivity into the interpersonal and constructionist space (with a “s”) as knowledge is co‐constructed through social interactions that value language, dialogue, and context ³ similar to a researcher/participants relationship. These initial conversations start with SW mostly listening:

I just want to hear Michelle's story, her background, her history and what made and makes MDL who she is…Then, if something in the story piques my interest, I'll prompt for some more info—see where it ranks in the order of importance (re narrative artefacts) to include in the final portrait. I'm designing the portrait in my head as we dialogue—pulling out aspects that could speak with strong visual metaphors in the image—and tie everything together. For MDL, the narrative was particularly rich, especially the anatomical side of things—and the many varied aspects of both her professional and personal life. (SW reflexive notes)

Throughout the co‐construction process, we were mindful to continuously pay attention and remain ‘wakeful’ to our own internal spaces (including our different values and practices) as we embarked on visually capturing MDL's full Depth of Field (across her interpersonal, social, political and cultural context) with a particular interest in how these inner and outer worlds came together through narrative portraiture. Just like the relationship between the researcher and participant, interpersonal subjectivity occurred through deepening conversations and social interaction, making decisions/imagining what MDL's narrative landscape looks like visually. For example, the background representing the outdoors and freedom of childhood play that nurtured her curious nature:

MDL: The background reminds me of my childhood, I was allowed to run free and be who I was. I would imagine what those burnt‐down buildings behind our house could be, creating this narrative in my head: Who lived there, what did they do? What was that building for and what fills it?

After the portrait was taken, GB documented her interpretations of the symbolism and narrative artifacts which she later shared with MDL. The following transcript taken from a conversation between MDL & GB demonstrated how they co‐constructed new and shared meanings below as MDL's reflexive awareness deepened, locating herself in the broader sociocultural research context from quantitative scientist (by training) to qualitative interpretivist (by choice):

GB: What's the circle and the square?

ML: That is a homage to the anatomy in the Da Vinci painting; after all, I am an anatomy educator, and yes, I love understanding the human body.

GB: OH, I thought the circle was for qualitative and the square represents quantitative? I see you standing in the middle as a translator between both paradigms. I love how the square is just above your head, like it contains you. But then the circle is outside which is very qualitative—allowed you to be bigger than yourself. You know I love that your right foot is stepping beyond the square, like a little active defiance, almost.

ML: It's funny because I viewed the Circle and Square, and my positivist versus interpretivist worldview as a negative before because I felt like people who grew up and were raised in the interpretivist world knew more, understood more, and I was the outsider yet again.

For portrait photographer SW, this did not come as a surprise, stating:

This is the interesting thing about interpersonal reflexivity and the process of engaging in narrative portraiture. The subject (MDL) will often see meaning in aspects of the image that are different to my original idea. While everything in the portrait is relevant to MDLs story it is mainly constructed from my original/initial perspective—however just like GB's reflection above, everyone, including the portrait subject, will interpret and read into each narrative artefact; word; pose; expression; differently, according to their own life experiences (SW reflexive notes).

The choice and placing of the words were also interesting in the portrait:

GB: What do the words mean? Why is academic in brackets?

ML: Because I think academic is the role I least identify with, it is too containing, being part of the system and structure—it is not who I see myself as.

GB: Why did you choose to place the word Creativity there?

ML: I think Creativity is the most proximal, whereas the most lateral is academic. I classified myself at some point in my journey as a scientist; I was a cell biologist. I truly believed I was a scientist. I thought at the time there was only one way of understanding the world. I don't identify as a scientist and while I don't identify as an academic, I do identify as a researcher.

For photographer Steve, the placing of the words was an important spatial element of the portrait stating:

I placed “Creativatis” (Latin for Creativity) next to the crochet piece in MDL's pocket. This represents her creative outlet away from her professional life as an anatomist, teacher and researcher. Her creativity keeps her grounded in the—“Terra” (Latin for earth that is placed next to the ball of wool). Latin was used throughout the narrative portrait as a nod to the standardised anatomical terminology used by the ‘Anatomist’ as the universal language to identify structures and functions. (SW reflexive notes)

These conversations represent the collaborative, interpersonal process of reflexivity and the shared meaning‐making (third voice) that emerged during the co‐creation of the narrative portrait. Below, we present a Table 1 of the authors interpretation of the symbolic narrative artifacts in MDL's portrait (Figure 1) to demonstrate how a social constructionist lens honors diverse constructions of the world ³ and how these interpersonal reflexive understandings evolve “beyond the original story itself”. ^{6 (p42)}

TABLE 1.

Authors interpretations of narrative portrait.

Narrative artifact	MDL's meaning	SW's meaning	GB's meaning	Example of shared/co‐constructed meaning
The heart	This has a dual meaning for me. (1) I tend to engage in the world around me by sticking what my passions are (e.g. my heart) (2) Represents the anatomical structure of a heart and also the subject that I teach first to the students	Central to anatomy and the Anatomist, representing this aspect of MDL's professional life. However, I was conscious that the heart represents many strong metaphors—and will be viewed as such. I found it interesting what we “chose” on the day to place on the left‐hand side and right‐hand side. I always have left vs. right brain (analytical vs. creative/emotional) in my mind when creating these portraits too	MDL is a wholehearted anatomist	MDL: The placement of the word superior is always going to be at my head—being mostly thinking. I think that's the challenge with ADHD, we aren't just thinking. We think with our hearts as much as our heads. We are very emotional. I don't know how to describe that better, but, like we are aware of our emotions, our emotions drive us more than the logic does. GB: A thinking heart? MDL: Not only am I taking a step towards that out of the square into the circle onto the grass, but that my heart, everything that is joyful and I'm passionate about is on the right side, and I fit into the world on the left side to achieve what's on the right side (I mean anatomical right‐ it's the left side of the picture). OH, MY GOD, I AM AN ANATOMY EDUCATOR, APPARENTLY….
The book	I can't stand reading, actually—but I love writing. It helps me formulate ideas and slow down the trains of thought. This book in particular has lots of meaning for me—the curiosity that I identify within myself, the body of research we have focused on and—finally—a core value of sharing this knowledge with the community through my first book	A recent proud moment for MDL—first book. Uncertainty tolerance resonates with me on many levels also	MDL is a writer and research leader in uncertainty tolerance	GB: What about the book? MDL: It took me until last year, through the writing of the book to share that I was diagnosed with ADHD over 20 years ago
The crochet hook	The hook has multiple meanings for me. One of the ‘superpowers’ that I identify with (that others also highlight about me) is my ability to weave diverse ideas into a single narrative, just as I do when I am crocheting. The crochet hook also represents the challenges I have with sharing my identity. I do not feel that my professional identity is the only one I have—my personal identity (my hobbies etc) is as much a part of me as my work	The Creative. The tool of MDL's creativity—the balancing force to her teaching/research. We also spoke about how it grounds MDL—especially in the ADHD space	I know MDL crochets as when we zoom she is always knitting another jumper!	MDL: I crochet because I like weaving things together, I am creating a thread…something new, something you can wear. This is important for my ADHD as concentration movement is part of the thinking, creates attentiveness in my world. I cannot see the world in any other way. GB: So how do you see the world? MDL: It's not linear, I feel like the portrait does a great job of illustrating my diversity. GB: Encompasses you as a whole? MDL: Yes—seeing the web of complexity that I see every day, the web is chaos. GB: I do not see chaos; I see like different worlds and I love how grounded you are in the centre of the portrait
The key	I was diagnosed with ADHD over 20 years ago. At the time it was seen as a disability—and I hid it and suppressed it for many years. But my brain works the way it works. Through these decades I have come to value my brain's ability to see and understand things from multiple points of view and see the solutions to many challenges almost immediately. My greatest challenge is typically not fixing a problem (as I already have the key)—it is in helping others get to and open the door (that I see too quickly)	I specifically remember from our first meeting the key and the multiple locks—a metaphor for explaining ADHD. You'll find the multi‐locks on the door to your left (right hand side of the portrait)	The key is for unlocking the door into her creative and imaginary world	GB: Tell me about the key around your wrist? MDL: In my adult life, I've been able to find structure, that space, that system, that I can open a door—from one side to the other, so I can go outside. I have finally learned in me that I can unlock the full potential of what I believe is my superpower, not a disability. I now have control over how and to what extent I move between the world of rigidity. GB: I like how the key is next to the crochet piece bringing together all the threads of color (MDL's life) together into something new

Engaging in the interpersonal reflexivity process with each other connected and evoked new meanings and purpose as scholars that goes beyond scientific positionality and flat reflexive statements that narrowly describe researcher's demographic or descriptive facts. Instead, this arts‐based approach provided a more rounded and thicker description of what life is really like for MDL being a qualitative researcher in an anatomist's world. This approach helped MDL go deeper into understanding herself and the world around her, opening her up “to the complex inner landscape of a human being, of a person's emotions, subjectivity, identity and personhood”. ^{6 (p43)}

CONCLUSION

In this viewpoint article, we have described the arts‐based approach of narrative portraiture to shine a light on the inner portrait of a HPE researcher, specifically MDL reflexive journey in a personal written reflexive statement and the interpersonal reflexivity all authors experienced co‐creating MDL's narrative portrait. We hope that this article stimulates conversations around the diversity of approaches to reflexivity practice and offer three core recommendations for novice HPERs interested in expanding their reflexivity in qualitative research: (1) Harness the richness of interdisciplinary teams to explore different ways, including art‐based approaches to richly represent reflexivity in your qualitative work. (2) Honor the subjectivity inherent in qualitative work as Olmos‐Vega and colleagues assert reflexivity “is not a limitation; it is an asset in your research”. ^{10 (p249)} (3) Prioritize reflexivity across the entire research process as it not only deepens interpretations of data by also deepens awareness and understandings of self and your evolving HPER identity. Finally, we have learned that there is reflexive power in narrative portraiture, bridging the inner and outer worlds, the lived and learned, personal and professional, positivist and interpretivist ways of seeing, knowing and being in the world.

AUTHOR CONTRIBUTIONS

Gabrielle Brand: Conceptualization; methodology; investigation; visualization; writing – original draft; writing – review and editing. Steve Wise: Conceptualization; methodology; visualization; writing – review and editing. Michelle D. Lazarus: Conceptualization; methodology; visualization; writing – review and editing.

FUNDING INFORMATION

No funding received.

CONFLICT OF INTEREST STATEMENT

No conflicts of interest to disclose.

ETHICS STATEMENT

Not required, viewpoint article.

Biographies

Gabrielle Brand is a nurse, qualitative narrative researcher, writer, mother, and expert vintage shopper. She is a Professor at Monash University Nursing & Midwifery and the Director of Graduate Research.

Steve Wise is a medical photographer, managing the Medical Multimedia Design Department at Royal Perth Hospital and a fine art portrait photographer outside of this role. He continues to explore collaborative narrative portraiture and is currently broadening this experience by slowing things down through the use of black and white large format film on his 1960's Linhof Color 4×5. Steve is also a musician, videographer and graphic designer.

Michelle D. Lazarus is still working out her professional and personal identity. Part of her identity is as a health professions education researcher, an anatomy educator, a friend, and expert crocheter. Her professional roles include being a Professor at Monash University in the Biomedicine Discovery Institute, Director of the Centre of Human Anatomy Education, and Deputy Director of the Monash Centre for Scholarship in Health Education.

DATA AVAILABILITY STATEMENT

No data within this article.