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Epistemology is a term used to describe theories about the nature of knowing. What we believe about what can be known shapes what we believe can be done with that knowledge. The beliefs about what can be known held by CBME and situated learning, that is, their epistemological foundations, are based in potentially postmodern concerns.

2.3.1

Postmodernity is a complex and rarely tackled topic in medical education. The last fifty years of medical education research have been vastly different from the first fifty years.28 The most recent period has been named both medical education’s second wave28 and its postmodern era.29-31 Defining modernity helps to clarify some of the ambiguities of postmodernity. Modernist thinking assumes that, by identifying and controlling variables, experimentally designed scientific study can uncover truths about human thought and behavior.32 The first wave of medical education research was largely based in behaviorism.28 It was characterized by attempts to experiment and control, to dig down

and isolate the kinds of thoughts that doctors have, both good and bad. This research made the assumption that, if researchers could objectively identify why and where doctors made mistakes, then educators could develop targeted interventions to train, to condition, them to no longer make those mistakes. This approach to the scientific study of human thinking operates according to a modernist logic.

Logical positivism, as a key facet of modernist thinking,30 claims that theories about the world can be proven true by attending only to facts without interpretation.33 Originally, logical positivism was a response to supposedly scientific work dedicated to solving moral and metaphysical problems, like proving the existence of a ‘human spirit,’ for example.34,35 By the 20th century, however, the discourse of objective truth in logical positivism and its ‘Scientific Method’ of hypothesis verification had become a tool used to silence scientists whose work or epistemological position precluded the very idea of objective truth.36

Work in the philosophy of science and in the basic sciences began to destabilize logical positivism’s assumptions about the possibility of unequivocal proof. In the philosophy of science, the work of Karl Popper and Thomas Kuhn marked waypoints in the process of understanding how inextricably human factors are embedded in the work of science.37,38 In physics, for example, the twinned ideas of inherent error—that any measurement of anything carried a modicum of bias or interpretation—and the observer effect—that making an observation changes the nature of the observed phenomenon— permanently altered the relationship between scientists in the natural sciences and their notion of truth.34,35,39

Philosophers of science began to collate these emerging ideas into a postpositivist understanding of science and knowledge. Postpositivist science rejects the idea that a theory can be verified to be true. Rather than verifying the truth of a theory, Karl Popper led the way toward the use of the null hypothesis and the primacy of falsification.37 Despite powers of modern knowledge generation, insisting on falsifiability means that science is limited to only ever inferring the validity of a theory by running out of ways to reject it. Postpositivism, therefore, is characterized as an approach to science that accepts the inescapability of interpretation. The measurements, the phenomenon itself, and even the research questions are subject to forces beyond our control and understanding.

Postpositivist science is a postmodern science. It is a science that comes after positivism, modernism, and the primacy of verifiability. It is fundamentally an interpretive science. Most importantly, it is science that is made reflexively aware of the limited degree of its powers to objectively understand the world.40,41

The postmodern era of science is a product of the decline of modernity and the logical positivism that defined it amongst philosophers of science and scientists themselves.30 The work of postpositivist philosophers such as Popper gave way to the postmodern ideas that arose in the second half of the 20th century. Medical education has adapted to these changes in scientific thought. My argument is that the second wave of medical education research shares in two of the major epistemological positions of postmodernity.42 Using the framework of Crotty,35 I will name these epistemological positions ‘constructionism’ and ‘subjectivism.’ Constructionism posits that, while the world is real, how we make meaning out of it is interpretive and our knowledge socially constructed. Subjectivism posits that there is no single reality and that meaning is not only interpretative but is also not necessarily tethered to any object, neither a natural one nor a constructed one. Subjectivism takes constructionist notions of knowledge even further down the postmodern epistemological continuum. To that end, subjectivism and constructionism are each necessary but singularly insufficient to define postmodernity.43

Relative to previous conceptions of science, subjectivism made room alongside constructionist research for scientific work drawing on subjectivist theoretical

perspectives such as critical theory, feminism, and postcolonialism,35,42 _{and together these}

epistemological perspectives have come to shape what today is called postmodernity.

2.3.2

Situated learning makes use of constructionist and subjectivist epistemological perspectives. But, even before looking that closely, the very notion that situated learning is a ‘theory’ is a postmodern notion. What counts as a learning theory is contested space. For those leaning towards modernist concerns, a theory is a testable hypothesis that explains how a phenomenon works.44,45 For others, a theory can be a framework for interpreting possible meanings at play in a situation.46-48 Accordingly, theories of learning used in medical education research can range from cognitive psychological theories— such as cognitive load49_{—to sociocognitive theories—such as distributed cognition}50,51_—

to sociocultural learning theories—such as situated learning. According to Sfard,26 at the cognitive end of this spectrum, knowledge is represented using an ‘acquisition metaphor’ and at the social end knowledge is represented using a 'participation metaphor.’ Sfard argues that these metaphorical representations convey different assumptions about what knowledge fundamentally is and what can possibly be known. That is, they hold different epistemological positions. Situated learning regards knowledge within the ‘participation metaphor,’ and thus positions situated learning as epistemologically postmodern.

Situated learning theory makes use of postmodern epistemological positions that are widely taken up in education research.18(p. 140 & 153-155) Kincheloe, for example, defines postmodernity as such: it concerns “the failure of reason, the tyranny of grand narratives [such as the notion of scientific progress], the limitations of sciences, and the reposition of relationships between dominant and subordinate groups”.52(p. 55) _{Situated learning is}

concerned with these same concepts. Subjectivist elements of situated learning are concerned with flattening hierarchy and resisting traditional conceptualizations of knowledge. Constructionist elements of situated learning are concerned with the

limitations of scientific objectivity, the constitutive nature of interpretation in knowledge development, and reconceptualizing the social structures that shape learning.

2.3.3

I wish to argue that competency-based medical education has the potential to be a second-wave product of medical education based on a postmodern epistemological position drawing on both constructionism and subjectivism. Competency-based medical education assumes that while we may not be able to glean stable objective truth about the ‘goodness’ of a doctor, what we can do is observe a phenomenon, measure it, and

interpret that data with the understanding that what we believe to be true about it is shaped by our social constructs. Medical education has explicitly taken on

constructionism as a valid epistemological position, positing that “judgements of real life performance in a social context will inevitably involve ‘subjective’ interpretation of ‘objective’ information”.20(p. 250, emphasis added) _{Outcome-based assessments used in}

competency-based medical education are an example of such a second-wave movement in medical education. In outcomes-based assessment, learners are assessed in actual clinical practice rather than the testing of abstract knowledge outside the clinical

environment. Outcomes-based assessment is predicated on the assumption that a person observing, interpreting, and judging the clinical work of another is a socially constructed but acceptably representative measure of performance53; while, objective-based

assessment, through multiple choice tests for example, is a modernist attempt to measure the amount of abstract knowledge an individual owns.54

CBME also approaches some problems from a subjectivist epistemology. Research methods that draw on subjectivist epistemologies such as critical discourse analysis, situational analysis, and participatory action research are postmodern forms of knowledge production. They are concerned with the idea of deconstructing the notion of a rational or objective person. They aim to bring silenced perspectives into official

conversation. They assume that discounted realities, theories that are believed to be untrue or irrelevant, are discounted not because they are objectively false but because they challenge the discourses of those in power.55 This kind of rethinking of professional values in CBME is based on the subjectivist epistemological position that there is no objectively researchable ‘good’ doctor; instead, there is only the subjective

understandings of what people want their doctor to be. The “relative absence” 17(p. 111) _of

documentation of competence and the increasing “need for programs to demonstrate how their graduates are meeting broader societal needs” 17(p. 13) _{are leading toward a need to}

more clearly justify the target of assessment. The perceived responsibility to “ensure the competence of qualifying specialist physicians”17(p. 112) _{is closely tied to a comprehensive}

assessment of the learners’ “meaningful demonstration of competent performance on each of the required components”. 17 (p. 113, emphasis added) _{Canadian CBME policies attempt}

to expand postgraduate medical education’s “disproportionate focus on the Medical Expert Role”17 (p. 110) _{by identifying 847 unique “competency milestones”} 56(p. 8-9) _“to

articulate a comprehensive definition of the competencies needed for all domains of medical practice and thus provide a comprehensive foundation for medical

education”.56(p. 3) _{Insisting on comprehensiveness and assessment beyond the medical}

expert role sets the CBME framework up as a potentially epistemologically postmodern one.

2.4

Medical education emphasizes the practical over the